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Updated on November 21, 2009

Is your unine red?

Gross hematuria (visible blood in the urine) can be one of the most frightening symptoms experienced by a patient. If encountered for the first time, a patient will notuncommonly consider it to represent an emergency and will sometimes present to the hospital emergency room with this complaint. Many patients who see blood in their urine fear the presence of cancer, and they remain uneasy until they have completed an evaluation to rule out this type of problem. Even microscopic hematuria can be quite upsetting to a patient when he or she is informed of this finding by the physician or through work-related testing.

Blood in the urine may be present in microscopic amounts (microhematuria) or it may be directly visible (gross hematuria). On occasion, a patient may complain of the finding of a spot of blood on the underwear. In male patients, this can actually be from bloody semen, not hematuria, whereas in females it might be caused by bleeding from a source within the vagina and not the urinary tract. Thus, spotting may or may not relate to hematuria but it should be noted as part of the history. If blood is present under the microscope, presumably the patient has been informed that a routine urinalysis showed microscopic bleeding (by chemical dipstick test, by the presence of red blood cells under the microscope, or both). It is especially important to find out if the patient has had previous reports of microhematuria or if this is the only occasion. If the hematuria is grossly visible, determination of the type of gross hematuria can be very helpful. Because a male usually voids in the standing position, he can view his urination from start to finish. This permits the male who experiences gross hematuria to be questioned as to whether the blood was seen only at the beginning of micturition (initial hematuria), at the completion of micturition (terminal hematuria), or throughout the entire voiding process (total hematuria). Blood in the ejaculate (hematospermia) is not related to hematuria per se, and it will not be a significant part of this discussion. Initial (gross) hematuria in the male indicates a urethral bleeding source. Terminal (gross) hematuria suggests a prostatic etiology, since the prostate constricts at the end of micturition (to eliminate small amounts of urine from the prostatic urethra). Total gross hematuria can be from any urinary tract source but commonly originates from the bladder or higher.

A female usually voids in the sitting position (or sometimes while squatting, as in a public restroom). A woman nearly always views her urine in the toilet bowel after voiding is completed. It is thus difficult to obtain a history from a female as to whether gross hematuria was initial, terminal, or total. However, a woman will often notice whether there was blood on the toilet tissue with wiping, or if the blood was merely seen in the toilet bowl before flushing.

different grades of red urine

Along with details regarding the hematuria, other information relating to voiding symptoms can be important in forming a differential diagnosis. Does the patient have dysuria, nocturia, frequency, urgency, incontinence, fever, chills, flank pain, hesitancy, or a history of previous genitourinary surgery or kidney stones? Is there any family history of genitourinary malignancy or nephrolithiasis? Was there any history of trauma, long-distance running, or extreme contact sports? What medication does the patient take? What other medical or surgical disorders does the patient have in his or her history?

In males, a sexual history should be obtained whenever possible. This should include the age virginity was lost, whether the hematuria has any relation to sexual activity, any previous sexually transmitted diseases, or any self-instrumentation or experimentation (not uncommon in younger males with spina bifida or other conditions that render the lower genitourinary tract insensate).

In females, a gynecologic history should be obtained. Details regarding menstruation should be obtained at the outset. Is the patient menstruating regularly? How many pads per day, how many days per menstrual cycle, and how many days between cycles? Is there a possibility of pregnancy? If the patient is a teenager, ask about age of menarche, regularity vs irregularity, frequency and severity of any accompanying pain, and type of pads used (internal vs external). Ask about previous pregnancies, live births, and miscarriages or abortions. Ask about the approximate date of the last Pap smear, whether or not it was normal, and if abnormal, what follow-up testing was performed. When feasible, obtain a sexual history, including age of loss of virginity, exposure to (or treatment for) sexually transmitted diseases, use of contraceptive devices or hormones, and other relevant information as befits the clinical circumstances. Sometimes simple inquiry into the correlation between sexual relations and the finding of hematuria can be very revealing, especially with microhematuria.

Causes of hematuria

It may be a Transient phenomenon of little significance or Sign of serious renal disease. It may be Macroscopicor Microscopic, Symptomatic or Symptomless, Transient or Persistent.

Kidney diseases like Acute Postinfectious Glomerulonephritis , IgA Nephropathy, Hereditary Nephritis (Alport syndrome), Benign Recurrent or Persistent Hematuria ( Thin Membrane Disease ) Membranoproliferative Glomerulonephritis, Crescentic Glomerulonephritis, Lupus Nephritis, Nephritis of Henoch-Shönlein Purpura, Focal Glomerulosclerosis, Hemolityc-Uremic Syndrome causes significant hematuria.

Causes of urinary tract related Hematuria include Infection, Urolithiasis, Obstruction ( UPJ Stenosis ), Trauma, Drugs ( Cyclophosphamide ), Tumors etc.

Hematuria not representing kidney or urinary tract disorder include Following exercise, Febrile disorders, Gastroenteritis with dehydration, Contamination from external genitalia.

In some conditions blood does not pass but urine is red which may be alarming to the patient eg some medicines like doxorubicin, cloroquine, desferoxamine, Ibuprofen, Iron sorbitol, Nitrofurantoin, Phenazopyridine, Phenolphthalein, Rifampin etc. Some food may also cause red urine like Beets (in selected patients), Blackberries, Food coloring agents etc.


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