Generality
The term hematuria indicates the presence of blood in the urine . It may be a visually appreciable phenomenon ( macroscopic hematuria ), or a subtle event, ascertainable only through the microscopic search for red blood cells in the urinary sediment.
What's this
Blood is normally a foreign substance to the composition of urine. For this reason, the finding of this clinical sign causes some concern.
The presence of red blood cells in the urine (the medical term is "hematuria") may originate from any point in the urinary tract :
- Kidneys;
- Ureters (which connect the kidneys to the bladder);
- Bladder;
- Urethra.
Even certain diseases that affect other parts of the body can determine the presence of blood in the urine. Furthermore, some causes can differ depending on the sex.
Hematuria can manifest itself in various ways:
- It can present itself as an isolated or recurrent episode.
- Urine may appear blood-colored (haematuria franca) or have a rosacea or turbid appearance. This feature may vary based on the severity of the bleeding and the timing with which it occurred:
- Frankish hematuria (red) : indicates a considerable bleeding in progress;
- Hematuria "meat washing" : indicates a slight bleeding;
- "Marsala" or "coca-cola" hematuria : may be associated with previous bleeding or the presence of hemoglobinuria.
- Sometimes, the body expels small blood clots, which make minimal changes to the color of the rest of the urine.
- Again, blood can only appear at the beginning of urination or in its final phase; the initial hematuria (ie present in the initial phase of urination) suggests a prostatic or urethral origin of the bleeding.
Many of the causes of hematuria are of absolutely benign origin (such as an urinary tract infection); others may portend an important disorder affecting vital organs (eg tumors or kidney diseases). For these reasons, you should consult your doctor or urologist as soon as possible.
macrohaematuria
We talk about macro - hematuria when the amount of blood in the urine is such that it is visible to the naked eye, or to change its color.
microhematuria
Microhematuria occurs when the quantity of blood eliminated is modest and is not visible to the naked eye; in this case the red blood cells are found in the urine test.
Urine appearance
In the case of macroscopic hematuria, the color of the urine varies according to the amount of blood lost; a hemorrhage of 1 ml is sufficient to make the phenomenon visually appreciable.
The macroscopic presence of blood in the urine generally makes the liquid take on the different shades of red. In some cases, however, blood traces can give the urine a different color. For example, when urinary pH is particularly acidic, the product of renal excretion takes on shades closer to dark brown.
Even when the urine is stationed for a long time in the urinary tract, the oxidation of hemoglobin present in the traces of blood makes them darker. On the contrary, in case of acute lesion, followed by rapid urinary elimination, the secretion assumes an intense red color.
Reddish urine is not necessarily synonymous with hematuria
The urine, produced by the activity of filtering the kidney and periodically eliminated with the act of urination, can take on a reddish color even in the absence of hematuria. This phenomenon may be due, for example, to some drugs (cascara-based laxatives, phenacetin, fentoina, ibuprofen, methyldopa, rifampicin) or to the conspicuous intake of certain foods (beetroot and rhubarb).
The urine can also be pigmented due to the presence, inside them, of bile salts, porphyries or urates. Finally, during menstrual flow, the apparent presence of blood in the urine may be due to contamination with vaginal blood loss or urinary tract endometriosis.
For all these reasons, in the face of suspected hematuria, it is very important to promptly perform a urine test, in order to obtain confirmation of the actual presence of blood inside them.
Why do you measure
In the presence of hematuria, a visit to the general practitioner or urologist allows the problem to be assessed by evaluating:
- Characteristics of hematuria : extent, coloration, permanence during all or part of urination;
- Possible presence of associated problems such as: trauma, pain, urination disorders, fever, pharyngeal infections etc.
After collecting the relevant clinical aspects of hematuria from the patient and evaluating the patient with the physical examination, the doctor will request the appropriate investigations to ascertain the cause.
The tests to be performed vary according to the case, but are generally performed:
- Urine test with urine culture, antibiogram and sediment assessment to assess the presence of any signs of kidney disease or urinary tract infections;
- Ultrasound of the urinary tract to determine the extent of trauma damage, the presence of stones or malformations of the urinary tract.
Normal values
Normally, in the urine no traces of blood are found and the erythrocytes are absent (or <3 GR) when examining the urinary sediment.
Causes
The urological causes of hematuria include:
- Cystitis (inflammation of the bladder wall);
- Urinary tract infections;
- Prostatitis;
- Benign prostatic hyperplasia, especially in men over 40 years;
- Prostate cancer;
- Kidney, ureteral or bladder stones;
- Diseases of the kidney (such as pyelonephritis, glomerulonephritis and chronic nephritis);
- Renal or urinary tract trauma (such as, for example, a blow to the lower part of the chest or a cutting wound);
- Cyst rupture (more frequent in case of polycystic kidney);
- Bladder, ureter or kidney tumors.
- Wilms tumor (in children);
Other causes responsible for the presence of traces of blood in the urine include:
- Drugs (anti-inflammatory drugs, NSAIDs, acetylsalicylic acid, warfarin or clopidogrel);
- Prolonged and repeated physical exercise (in particular, the marathon);
- Dysfunction of platelet aggregation or coagulation, acquired or congenital;
- Endocarditis;
- Malaria;
- Schistosomiasis;
- Severe burns.
False hematuria (pseudohematuria)
Alongside all these causes, there are also false positives that can make the urine of a reddish pigmentation, not easily distinguishable from hematuria.
In women of child-bearing age, for example, menstrual losses can sometimes be mistaken for hematuria. In these cases, the unusual urine color disappears with the end of menstruation.
Excessive intake of certain foods (in particular: beets, blueberries, rhubarb and food coloring) or certain drugs (such as rifampicin) can also color urine red or darker in color.
The urine is also tinged with red in the case of myoglobinuria (elimination of myoglobin caused by muscle damage) or hemoglobinuria (caused by intense hemolysis as in favism crises).
Hematuria can also occur in the presence of traces of porphyrins (intermediates in the biosynthesis of hemoglobin) and urates, but endometriosis can also alter the color of the urine.
The cases of false hematuria can be unmasked by a careful examination of the urine with evaluation of the sediment.
Symptoms associated with hematuria: what are they?
The presence of blood can be totally asymptomatic (haematuria "a ciel serene") or be associated with other irritative disorders, such as difficult urination and production of a decidedly different urine from the straw yellow color of normality.
Symptoms such as urination urgency (impellent feeling of peeing), pollakiuria, fever, chills and burning are typical of a urinary infection, which should be diagnosed with an appropriate culture test.
Pain located on one side of the abdomen, which radiates to the back, groin and genital area, may depend on the presence of kidney or urethral stones.
How to measure it
To assess the causes of hematuria, it is necessary to collect a small amount of morning urine, fasting.
Preparation
Urine should be collected in a sterile disposable container. This should be carefully closed immediately afterwards and should be taken to the laboratory within two hours.
For some tests, however, it is necessary to collect all the urine emitted over a whole day (24 hours). In this case, large containers (2 to 3 liters) must be used.
Diagnosis
Urine, produced by the kidney, is conveyed into the bladder through small tubes called ureters; from here, through the urethra, it comes out outside with the act of urination.
For this reason, until a few years ago the diagnosis of hematuria was based on the test of the three glasses . During this examination the patient is invited to urinate, without interrupting the jet, in three glasses. From what has been said so far, if you have blood urine only in the first glass it means that the bleeding has occurred at the urethral level; if the macroscopic hematuria becomes evident in the third calyx, or if the coloring becomes more and more intense as the flow continues, it is probably bladder hemorrhage, slight in the first case and more serious in the second; finally, if there are traces of blood in all three glasses, it is generally a haemorrhage upstream of the urinary tract, that is, at the level of the kidneys or ureters.
Today, the examination of the three glasses has fallen into disuse due to the advent of more modern and effective technologies in identifying the origin of the problem. It should not be forgotten that hematuria is not a diagnosis, but a symptom of a potentially serious condition. Consequently, a timely and accurate diagnosis is essential before choosing the appropriate therapy.
The most used techniques are:
- Renal, bladder and prostate ultrasound;
- Urography;
- Urotac
- urethrocystoscopy;
- Ureteropieloscopia;
- Abdomino-pelvic CT scan.
The pathologies most frequently associated with the discovery of blood in the urine are the presence of calculi, neoplasms or inflammations in the kidney, bladder or urinary tract.
Hematuria can also be linked to tuberculosis, cystitis, use of anticoagulant drugs, polycystic kidney disease, prostatitis, prostate adenomas or traumas involving the kidney and / or the urinary tract. Finally, in athletes, cases of stress hematuria have been described, especially after intense and prolonged physical activities such as the marathon or cycling.
The evaluation of the associated symptomatology is fundamental for an initial diagnosis, while awaiting appropriate investigations. For example, if blood loss with urine is concomitant with colonic or gravitational lumbar pain, it is probably due to the presence of kidney or urethral stones.
If hematuria is associated with difficulty in urinating, or appears during defecation, it could be prostatic disease.
Interpretation of Results
The degree of alarm in the detection of blood in the urine varies considerably: it may be mild and easy to treat, or severe and potentially fatal.
The finding of blood in the urine is a symptom that must never be ignored. If recurrent, its importance increases. Regardless of whether the hematuria is copious or present in very small traces, it will always be the doctor who will assess the situation and establish the best therapeutic approach to the problem.
Treatment
The treatments depend on the type of disease that caused the disorder.
- If blood loss in the urine is linked to an infection, the therapy is based on the administration of antibiotics. A conscientious doctor will advise the use of narrow-spectrum drugs, after evaluating the results of the antibiogram, a very useful test to identify the most suitable drug to fight the pathogen in question. This ethically correct procedure minimizes the risk that the various pathogens develop antibiotic resistance.
- In the presence of kidney stones various techniques are used, ranging from the classic "shot of water", to the crushing of these mineral aggregates by means of shock waves, lasers or mini-invasive mechanical means (see: treatment and treatment of kidney stones).
- In the case of mild (or first-degree) prostatic hypertrophy, the therapy is pharmacological (anti-inflammatory, muscle relaxants, inhibitors of the enzyme 5-alpha reductase). For moderate or severe prostatic hypertrophy, the endoscopic removal of the enlarged portion is generally carried out (minimally invasive surgery).
