Synopsis
Stabilise significant urinary bleeding, distinguish glomerular from urological sources and apply current cancer, infection, stone and nephrology pathways to visible or persistent non-visible haematuria.
- First decide whether blood is visible or detected on reagent strip, painful or painless, and accompanied by clots, infection, obstruction or physiological instability.
- Confirm that red urine is blood: beetroot, rifampicin, porphyria, haemoglobin and myoglobin can change colour or the dipstick result. Menstrual or genital bleeding may contaminate a sample.
- Painless visible haematuria is a urinary malignancy signal until appropriately investigated. Anticoagulants and antiplatelets can increase bleeding but do not remove cancer or stone risk.
- NICE recommends a suspected-cancer referral for people aged 45 or over with unexplained visible haematuria without UTI, or haematuria persisting or recurring after successful UTI treatment.
- For bladder cancer, NICE also recommends urgent referral in people aged 60 or over with unexplained non-visible haematuria plus dysuria or a raised peripheral white-cell count.
- Clots usually point to non-glomerular bleeding and can obstruct the bladder outlet. A three-way catheter and irrigation require competent urological technique and caution if urethral injury is possible.
- Painful haematuria suggests stones, infection, trauma or retention, but pain does not exclude malignancy and absence of haematuria does not exclude a CT-proven stone.
- Smoky or cola urine, dysmorphic red cells, red-cell casts, proteinuria, hypertension, oedema and impaired function support glomerular bleeding and a parallel nephrology pathway.
- Do not use urine microscopy to count red cells as the sole confirmation of non-visible haematuria in adults when NICE recommends reagent-strip detection; microscopy remains valuable for renal localisation.
- A negative initial urological investigation needs explicit safety-netting and renal surveillance when haematuria, albuminuria, hypertension or declining eGFR persists.
Key red flags
Fresh dark-red urine, clots, inability to void, suprapubic pain, blocked catheter, haemoglobin fall or circulatory compromise indicates clinically important bleeding and possible clot retention.
Painless visible haematuria, smoking, aromatic-amine exposure, age, prior pelvic radiotherapy or cyclophosphamide increases concern. Intermittent bleeding is not reassuring.
Colicky flank-to-groin pain, restlessness, nausea and haematuria suggests ureteric stone; fever, rigors and loin tenderness suggests pyelonephritis. Their combination raises infected obstruction risk.
Brown urine without clots, albuminuria, dysmorphic erythrocytes or red-cell casts, hypertension and oedema supports glomerular origin, especially with rash, arthritis or haemoptysis.
Recent catheterisation, biopsy, surgery or blunt injury changes the likely source. Blood at the urethral meatus or pelvic fracture signs require senior urology input before blind catheterisation.
Investigation priorities
Confirm haem pigment, detect infection and protein, and assess renal sediment when indicated.
Management branches
Clots, retention, catheter blockage, haemoglobin fall, heavy ongoing haematuria or instability.
- Perform ABCDE, obtain IV access, FBC, group and save/crossmatch, renal profile and coagulation, and review antithrombotic indication with senior help.
- If clot retention is present and urethral injury is not suspected, involve urology for an appropriate large-bore three-way catheter, manual washout and continuous irrigation under local practice.
- Escalate persistent bleeding for cystoscopic clot evacuation or haemostatic intervention; treat sepsis and decompress an obstructed upper tract urgently when present.
Incidental reagent-strip blood in a clinically stable patient.
- Address menstruation, exercise and infection, then repeat at the recommended interval; quantify ACR, measure blood pressure and retrieve eGFR trend.
- Use NICE cancer referral criteria where age and associated dysuria or raised white count qualify, and use urology advice for persistent unexplained bleeding or risk factors.
- Discuss with nephrology when proteinuria, renal impairment, hypertension, casts or systemic features suggest renal origin, continuing longer-term monitoring after a negative work-up.