Diagnosis of Hematuria

Hematuria Classification

Bleeding is classified by when it occurs during urination, which may indicate the location of the problem.

  • Onset of urination (initial hematuria)–urethra or prostate (men)
  • Throughout urination (total hematuria)–bladder, ureter, or kidneys
  • End of urination (terminal hematuria)–bladder or prostate (men)

Symptoms may indicate the site and/or cause of bleeding:

  • Abdominal pain–inflammation of the kidney or ureter caused by trauma, infection, or tumor
  • Decreased urinary force, hesitancy, or incomplete voiding–lower urinary tract, benign prostate hyperplasia (BPH, enlarged prostate), tumor
  • Fever–infection, typically kidney infection, prostate infection, or urethral infection
  • Pain in the flank–kidney trauma or tumor
  • Urinary urgency, pain, or frequency–bladder cancer

The physician takes a complete personal and family medical history. The personal history can provide useful information:

  • Drinking and smoking history
  • Exposure to toxic substance dating back 25 years or more
  • History of kidney stones
  • Injuries and infections
  • Recent and past drug use
  • Recent illness
  • Sexually transmitted disease (STD) exposure
  • Urinary habits

The family history may reveal inherited predispositions to kidney stone disease, sickle cell anemia, von Hippel-Lindau disease, or another genetic disorder associated with hematuria.

A thorough physical examination is performed, with emphasis on the urinary tract, abdomen, pelvis, genitals, and rectum.

Hematuria Tests

In cases of suspected microscopic hematuria, a sample of the patient's midstream urine is applied to a chemically treated strip. The chemical changes color if blood is in the urine. The intensity of the color indicates the amount of blood present. This test (called a dipstick test) is performed in the doctor's office.

A positive result warrants examination of the urine under the microscope to look for the presence of cancer cells (urine cytology). A urine culture may be grown to check for various infections. The tests may be repeated on a 24-hour collection of the patient's urine, and a blood chemistry workup may be ordered.

Cystourethroscopy, or cystoscopy, is performed when the cause of gross or microscopic hematuria cannot be identified. Local anesthesia is given, and a small, rigid or flexible fiber-optic instrument is inserted into the urethra. The physician can visually inspect the urethra, bladder, and prostate through the cystoscope. The procedure takes about 10 minutes. Some patients experience minor short-term discomfort with urination or slight spotting of blood over the next couple of days.

Intravenous pyelogram (IVP) is a special x-ray procedure in which a colorless dye containing iodine is injected into a vein in the patient's arm. The dye collects in the urinary system and provides enhanced contrast for a series of x-rays taken over 30 minutes. This produces a better image of the kidneys, ureters, and bladder and can reveal stones, tumors, blockages, and other possible causes of hematuria. After the procedure, the patient may be asked to go to the bathroom, completely empty their bladder, and return for a final x-ray.

Patients who previously had an allergic reaction to intravenous dye or to shellfish should tell their doctor before undergoing an IVP.

If these tests fail to show the cause of hematuria, ultrasound or computer-assisted tomography (CAT scan) may be ordered.

Hematuria Differential Diagnosis

When no specific cause can be found, bladder and kidney stones, cancer, and other life-threatening diseases can be ruled out. The possible causes that remain include conditions that may correct themselves, or the hematuria may be idiopathic. Men over the age of 50 with no clear diagnosis should have a yearly prostate specific antigen (PSA) test to screen for prostate cancer.

Publication Review By: Stacy J. Childs, M.D., Stanley J. Swierzewski, III, M.D.

Published: 14 Jun 1998

Last Modified: 18 Sep 2015