Introduction
Haematuria is one of the most important urology OSCE stations because visible (macroscopic) haematuria in an adult over 45 requires urgent investigation to exclude bladder cancer. You must characterise the haematuria systematically, identify red flags, and know when to refer urgently.
💎 Clinical Pearl
Clarify at the outset whether the blood is truly in the urine: menstrual blood, rectal bleeding, and haematospermia can all be confused with haematuria. Ask: "Did you see the blood in the toilet bowl, or in the urine stream itself?"
Terminology
| Term | Definition |
|---|---|
| Visible haematuria (VH) | Blood visible to the naked eye (previously macroscopic) |
| Non-visible haematuria (NVH) | Blood detected only on urine dipstick or microscopy (previously microscopic) |
| Frank haematuria | Blood throughout the urinary stream |
| Initial haematuria | Blood only at the start of stream — suggests urethral source |
| Terminal haematuria | Blood only at the end of stream — suggests bladder neck or prostate |
| Total haematuria | Blood throughout — suggests renal, ureteric, or bladder source |
Characterising the Haematuria
Timing in Urinary Stream
See table above — initial, terminal, or total is diagnostically useful.
Clots
- Clots present: suggests more significant bleeding (bladder tumour, renal carcinoma)
- Clot shape: worm-like "snake clots" = ureteric origin (renal pelvis or ureter bleeding)
Associated Symptoms
| Associated symptom | Suggests |
|---|---|
| Dysuria, frequency, urgency, fever | Urinary tract infection |
| Severe loin-to-groin colicky pain | Ureteric calculus (renal stone) |
| Painless haematuria | Bladder cancer or renal cell carcinoma until proven otherwise |
| Flank pain, mass, weight loss | Renal cell carcinoma (classic triad) |
| Hesitancy, poor stream, nocturia, frequency | Prostate pathology (BPH, prostate cancer) |
| Rash, arthralgia, haematuria | IgA nephropathy (Berger's disease), SLE, vasculitis |
| Haematuria during or after URTI | IgA nephropathy (synpharyngitic haematuria) |
Differential Diagnosis
🧠 Mnemonic
BUTS — Bladder, Urethra, Tumour/tract (renal), Systemic
- Bladder: transitional cell carcinoma (most common), cystitis, bladder stone
- Ureter and urethra: calculus, transitional cell carcinoma of ureter
- Tumour/tract (renal): renal cell carcinoma, IgA nephropathy, ADPKD, pyelonephritis, infarction
- Systemic: coagulopathy (warfarin), glomerulonephritis (SLE, vasculitis), sickle cell, haemophilia
- Prostate: BPH, prostate carcinoma, prostatitis (causes terminal haematuria)
Painless Visible Haematuria
⚠️ Red Flag
Painless visible haematuria in anyone over 45 = bladder cancer until proven otherwise. This is the most important red flag in urology. Do not attribute it to a UTI without investigation — bladder cancer commonly coexists with UTI.
Risk Factors for Urothelial Carcinoma (Bladder Cancer)
| Risk factor | Example |
|---|---|
| Smoking | Single biggest risk factor |
| Occupational chemical exposure | Aniline dyes, rubber industry, leather workers, painters |
| Chronic cyclophosphamide use | Haemorrhagic cystitis and bladder cancer |
| Phenacetin (historical analgesic) | Urothelial malignancy |
| Pelvic radiotherapy | Increased risk |
| Schistosomiasis | Squamous cell carcinoma of bladder (endemic areas) |
| Chronic catheterisation | Squamous metaplasia |
Red Flags and 2-Week Wait Criteria
⚠️ Red Flag
Refer urgently (2-week wait) for haematuria if:
- Aged 45+ with unexplained visible haematuria without UTI
- Aged 45+ with visible haematuria that persists after UTI treatment
- Aged 60+ with unexplained non-visible haematuria and dysuria or raised PSA
- Recurrent or persisting non-visible haematuria with risk factors (occupational exposure, smoking)
Other Key History Components
Past Medical History
- Previous urological conditions: renal stones, recurrent UTIs, bladder pathology
- Previous malignancy (renal, pelvic)
- Bleeding disorders
- Sickle cell disease
Drug History
- Anticoagulants (warfarin, DOACs): haematuria on anticoagulation still needs investigating — do not blame the anticoagulation alone
- Cyclophosphamide
- Rifampicin, pyridium: cause orange-red urine, not blood
Family History
- ADPKD (autosomal dominant polycystic kidney disease): FH of renal cysts, hypertension, subarachnoid haemorrhage
- Family history of renal cancer
How to Present
"This 62-year-old male ex-smoker presents with a 3-week history of painless visible haematuria throughout the urinary stream, with no dysuria, frequency, or loin pain. There are no clots. There is no family history of urological malignancy. He has no anticoagulant use. Painless visible haematuria in this age group represents a bladder or renal malignancy until proven otherwise. I would refer urgently under the 2-week wait rule and arrange flexible cystoscopy, urine cytology, and a CT urogram."
"What is the most important cause to exclude in a patient with painless visible haematuria?"
Bladder transitional cell carcinoma (urothelial carcinoma) is the most important diagnosis to exclude, particularly in patients over 45. Painless visible haematuria is the classic presenting symptom. Smoking is the single biggest risk factor. All patients over 45 with unexplained visible haematuria must be referred urgently under the 2-week wait rule for flexible cystoscopy and CT urogram.
"How do you distinguish upper tract from lower tract haematuria?"
Upper tract (renal and ureteric) haematuria typically causes total haematuria or worm-shaped clots (formed as blood tracks down the ureter). It is often associated with loin pain (stones, tumour). Lower tract haematuria from the bladder causes total haematuria with irregular clots; from the urethra, initial haematuria; from the prostate or bladder neck, terminal haematuria. CT urogram visualises the entire upper tract and bladder.
"What would you say to a patient who thinks their haematuria is just a UTI?"
Explain that while a UTI can cause haematuria, it is important to check that the blood goes away completely once the infection is treated. If haematuria persists after a course of antibiotics, or if there is no confirmed infection, it must be investigated further — as blood in the urine can sometimes be an early sign of a problem in the bladder or kidney that is much easier to treat if found early. Reassure that investigation (cystoscopy and scan) is straightforward.
"What is synpharyngitic haematuria and what does it suggest?"
Synpharyngitic haematuria is visible haematuria occurring during or within 1-2 days of an upper respiratory tract infection. It is the classic presentation of IgA nephropathy (Berger's disease), the most common primary glomerulonephritis worldwide. Unlike post-streptococcal GN (which presents 2-3 weeks after pharyngitis), IgA nephropathy occurs concurrently with the infection due to IgA immune complex deposition in the mesangium.
Related guides: Urology History OSCE | Abdominal Examination OSCE | Blood Results Interpretation OSCE