Bladder Symptoms and Gross Hematuria
Bladder symptoms and gross hematuria, or visible signs of blood in urine, can indicate the presence of an underlying urinary condition. The color of your urine can vary without you having a medical issue. In women, blood from a menstrual cycle can mix with the urine during urination. One day your urine can be clear and water-like and another day it can be a dark amber color. Sometimes your urine may look red, blue or green in color. The changes in urine color and increased cloudiness can indicate your level of hydration, the types of foods that you have eaten, or medications you have taken. Bladder symptoms and gross hematuria should not be overlooked, however. Sometimes bloody urine appears due to a bladder tumor or urinary tract infection. Bladder tumors may bleed and the cancer bladder invasion my grow down and spread throughout the bladder wall if not caught in time. When you have a bladder infection because of bacteria that has entered the urinary tract, you could suffer from an inflamed bladder that will become irritated and create a buildup of red blood cells that will be released into the urine. Red urine or red specks in the urine could also be signs of blood in the urinary tract because of a kidney stone. As kidney stones pass through the urinary tract, they can scrape against the walls of the kidneys, ureters, bladders, and urethra and cause bleeding. A bladder stone is similar to a kidney stone in that it is formed by minerals that crystallize in the urine when the urine becomes concentrated. This is usually the result of an enlarged prostate, damage to a nerve, or urinary tract infections that reoccur. Bladder stones that are small can pass in the urine with little or no symptoms, however large bladder stones can cause obstruction with abdominal pain and blood in urine. Bladder symptoms and gross hematuria should not be overlooked. While gross hematuria can be seen with the naked eye, conversely microscopic hematuria, or microhematuria for short, are tiny traces of blood that can only be seen under a microscope. Microhematuria is normally detected through roUTIne urinalysis. However, just because the traces of blood in urine are small, that does not mean that the problem causing the microscopic hematuria is small. Any indication of a urinary problem, whether it is a symptom that you can see or feel or something that is detected on a diagnostic test or medical exam, needs a proper evaluation and diagnosis…
Hematuria is BLOOD in the URINE. Hematuria may result from numerous circumstances and always requires medical evaluation to determine the underlying cause. Though BLADDER CANCER is uncommon, hematuria often is the earliest sign of its presence. Gross hematuria occurs when the amount of blood in the urine is sufficient to discolor the urine (typically pink, red, or brown). Occult, or microscopic, hematuria occurs when the amount of blood in the urine is very slight, detected during microscopic examination of the urine.
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Figure 2.
Intravenous urogram of transitional cell carcinoma in a 60-year-old woman with a two-month history of intermittent left flank pain and microscopic hematuria. Left side down oblique view at 18 minutes confirms small polypoid mass (arrows) arising from the medial wall of the renal pelvis.
RENAL ULTRASONOGRAPHY
Ultrasonography (Figure 3) is the least expensive and safest choice for evaluating microscopic hematuria because it does not expose the patient to intravenous radiographic contrast medium. It is also an appropriate choice for the evaluation of hematuria during pregnancy. Although ultrasonography is limited in its ability to detect solid tumors that are less than 3 cm in diameter,22 masses 3 cm or greater in diameter, cysts, and hydronephrosis are detected with a high degree of sensitivity.20 Ultrasonography has been found to be more sensitive than intravenous urography in detecting renal cell carcinoma but less so in detecting urothelial transitional cell carcinoma.1,20 The sensitivity of ultrasonography for detecting renal calculi has been found to be 64 to 96 percent, significantly lower than with noncontrast CT.20
Figure 3.
Ultrasound of renal carcinoma in a 51-year-old man with head and neck carcinoma and incidental hematuria noted on routine urinalysis during follow-up. Transverse scan through the lower pole shows lateral exophytic mass (arrows) in relation to the normal kidney tissue (K). Renal carcinoma was proven at surgery.
COMPUTED TOMOGRAPHY
Microscopic hematuria associated with renal colic is best evaluated with CT in light of its high sensitivity for identifying renal calculi.21,23 Unenhanced helical CT (Figure 4) is more accurate for evaluating patients with renal colic compared with ultrasonography, intravenous urography, or plain radiography and has replaced these imaging techniques as the test of choice in many institutions.23 When compared with intravenous urography, unenhanced helical CT has the advantage of higher accuracy, decreased radiation dose, faster examination time, and improved sizing and localization of stones.
Figure 4.
Unenhanced helical computed tomogram of urolithiasis in a 49-year-old woman with a three-day history of dull right flank pain radiating to the groin and microscopic hematuria. Image shown at the level of the renal sinus. The right kidney is enlarged and shows hydronephrosis (long arrow). Note tiny right renal calculus (short arrow). Left kidney is normal.
Contrast-enhanced CT (Figure 5) has favorable sensitivity over intravenous urography or ultrasonography for identifying small renal parenchymal masses. Contrast-enhanced CT also enables detection of aneurysms in vessels that run along the ureter, a potentially life-threatening, albeit uncommon, condition.21 Renal and perirenal abscesses are best evaluated by contrast-enhanced CT.1 After a renal mass has been identified by intravenous urography or ultrasonography, CT likely would be indicated as follow-up evaluation to better characterize the mass as a simple cyst, complex cyst, or solid mass, or to stage for surgical planning. This alone may warrant initial evaluation by CT despite its higher cost.
Figure 5.
Contrast-enhanced computed tomogram of a small renal carcinoma in a 59-year-old asymptomatic woman with microscopic hematuria. Delayed scan shows definite delineation of small right renal mass (arrow).
Although not widely supported in the literature, magnetic resonance imaging can be used to assess the upper urinary tract. Its high cost and lack of availability in many locations often are prohibitive, and CT is approximately as sensitive in detecting small parenchymal masses.7 In select cases, angiography may be helpful if a small arteriovenous malformation is a concern.7
Evaluation of the Lower Urinary Tract
Identifying an abnormality in the upper urinary tract does not preclude evaluation of the lower urinary tract because a comorbid lesion may exist. The etiology of asymptomatic microscopic hematuria remains unclear in 70 percent of patients after imaging of the upper urinary tract and assessment of urine for signs of glomerular disease.2 Urine cytology studies and cystoscopy are used routinely to evaluate the lower urinary tract.
URINE CYTOLOGY
The AUA recommends that patients with microscopic hematuria have radiographic assessment of the upper urinary tract followed by urine cytology studies.1 Voided urine cytology studies are less sensitive (66 and 79 percent in two studies) than cystoscopy for the evaluation of bladder cancer.2 The sensitivity can be optimized by following urine collection protocols in which urine is collected from the first void of the morning on three consecutive days.2 Urine cytology does, however, have high specificity (95 and 100 percent in two studies).2 The sensitivity of urine cytology is highest for detection of high-grade lesions in the bladder and carcinoma in situ.24 The primary advantage of urine cytology versus cystoscopy is that because it is noninvasive, it does not cause the patient any discomfort. Urine cytology is limited in its ability to detect low-grade lesions in the bladder as well as renal cell cancer.24
CYSTOSCOPY
The AUA recommends that all patients older than 40 years and those who are younger but have risk factors for bladder cancer obtain cystoscopy to complete the evaluation of microscopic hematuria.1 Abnormal urine cytology findings also would necessitate cystoscopy, which has 87 percent sensitivity for bladder cancer.2 Cystoscopy is the only reliable method of detecting transitional cell carcinoma of the bladder and the urethra.8 The primary disadvantages of cystoscopy are patient discomfort with this invasive procedure and its limited ability to detect carcinoma in situ of the bladder.24
Follow-up
There has been some debate about the recommended follow-up for patients with idiopathic microscopic hematuria. An acceptable approach would include repeat urinalysis with urine cytology every six months and repeated cystoscopy every year.6 This is especially important for persons older than 40 years and younger persons who have risk factors for urothelial cancer (i.e., smoking history, occupational exposure to benzenes or aromatic amines [e.g., leather dye, rubber, tire industries], or history of urologic neoplasm).
Understanding the strengths and weaknesses of each radiographic modality with data from the history and physical examination can help family physicians select the most appropriate starting point for evaluation of the upper urinary tract. Urine cytology studies alone may provide sufficient evaluation of the lower urinary tract in certain low-risk patients. It should be emphasized that patients older than 40 years and those who have identifiable risk factors for urothelial neoplasms merit referral to a urology subspecialist for cystoscopy.
Disclaimer: These Wellness Protocols are not intended to replace the attention or advice of a physician or other qualified healthcare professional. These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease.
