Blood in Urine

The medical term for the presence of blood in the urine under is haematuria. It may or may not be accompanied by other symptoms. It may be transient or persistent for long periods, or may be an isolated feature. Sometimes, there may be a presence of proteins (proteinuria) in the urine along with haematuria.

It indicates that there is an underlying problem in the urinary or genitourinary system that triggers bleeding. Blood in the urine is usually harmless in many cases, but sometimes can be an alarming symptom of a serious disease. Several diseases such as UTIs and kidney stones can lead to blood in the urine. However, other pathologies must also be considered in cases of chronic blood in the urine. If the doctor rules out benign reasons that may cause blood in the urine, other investigations are advised to rule out more serious causes.

There are two types of blood in urine:

• Macroscopic Haematuria
  If the urine appears red to the naked eye, it is known as macroscopic haematuria. Even 1 mL of blood in the urine can give it a reddish tinge. Macroscopic haematuria should be thoroughly examined, as it is of a major concern. The incidence of macroscopic haematuria ranges from 1-6 % but has also been as high as 19%. UTIs and kidney infections known as pyelonephritis are said to be the most common causes of macroscopic blood in the urine.
• Microscopic Haematuria
  If blood is only detected after the examination of the urine under a microscope, it is termed microscopic haematuria. Alternatively, more than 10 red blood cells should be detected on a high field microscopic evaluation to be termed as microscopic haematuria.

Blood in the urine is an accompanying symptom of an underlying condition. Symptoms specific to certain conditions may be associated with blood in the urine.

• Pink or cola-coloured urine due to the presence of red cells.
• Pain and burning sensation during urination. (Read more - Painful urination causes and treatment)
• Fever with chills.
• Nausea and/or vomiting.
• Pain in the lower abdomen and flanks. (Read more - Stomach pain causes and treatment)
• Fluctuating periods of pain.
• Difficulty in passing urine.
• A weak or interrupted flow of urine.
• Leakage of urine while laughing, sneezing or coughing. (Read more - Cough treatment).
• Blood in semen.
• Increased frequency of urination.
• Discomfort in the penis or testes. (Read more - Penis pain causes and treatment)

Causes

Macroscopic, as well as microscopic blood in the urine, can be a common feature of benign as well as malignant (cancerous) conditions of the urinary system. The main causes that lead to blood in the urine are as follows:

• Urinary Tract Infections
  UTIs can occur in any region of the urinary system. A majority of the infections are related to the lower urinary tract, which includes the urinary bladder and urethra. The risk of UTIs is higher in women than in men because women have a smaller urethra than men, and the distances from the urethra to the bladder and the urethra to the anus are also shorter than those in men. Also, as the vagina is close to the urethral opening, sexually transmitted infections, herpes, or gonorrhoea can also cause UTIs. Women after menopause may also be more susceptible to infections due to a fall in the oestrogen levels. Escherichia coli, a bacterium usually found in the gastrointestinal tract, is the most common organism causing UTI. In most instances, a person can recover from a UTI after taking medicines, but there can be serious complications if the infection spreads to the kidneys. 
• Kidney or Bladder Stones
  Hardened deposits of salts and minerals that are formed within the bladder and kidneys are known as stones. It can affect any part of the urinary tract. When the urine becomes concentrated, the minerals begin to crystallize and harden, forming a stone. Kidney stones are mainly formed of calcium oxalate. Oxalates are found naturally in the body and are made by the liver. Certain foods, such as chocolates and nuts, have high oxalate content. People following a diet high in proteins, sodium or sugar may increase the risk of stones. Obesity is also associated with a higher risk of kidney stones. It can be painful while passing stones in the urine and the passage may be blocked by stones if they are large enough. If stones obstruct the urinary tract, it may lead to infections and other complications. Usually, kidney stones do not produce any symptoms unless they are moving in the kidney or travel into the bladder or ureter.
• Kidney Infections
  Kidney infections, also known as pyelonephritis, begin as a urinary infection and spread into the bladder or kidneys. The bacteria entering the urinary tract multiply and travel upwards. Infections from other places in the body can also spread through the blood into the kidneys. Women, particularly pregnant women, are at a higher risk of infections. Conditions, such as kidney stones, enlarged prostate, diabetes, HIV, and spinal cord injury increase the risk of kidney infections. Kidney infections need to be treated immediately, or they may lead to further complications, which can damage the kidneys. The bacteria causing the infection may enter the bloodstream and may cause life-threatening complications.
• Enlarged Prostate Gland
  Prostate gland enlargement is a common condition in older males. An enlarged prostate can lead to difficulty while urinating and block the urinary bladder leading to kidney diseases. The urethra passes through the centre of the prostate gland situated beneath the bladder. When the gland is enlarged, it blocks the flow of urine. The exact cause of prostate enlargement remains unknown, but male sex hormones probably influence the growth of the gland. Certain risk factors, such as advanced age; a family history; and certain diseases, such as high blood pressure, diabetes, and obesity, increase the risk of prostate enlargement.
• Cancers
  Almost 9 out of 10 kidney cancers are renal cell carcinomas. However, most kidney cancers are detected before spreading to other organs, and such cases respond better to treatment. Bladder cancers are rarer than kidney cancers.
• Other causes
  • Uric acid stone.
  • Pelvic trauma.
  • Menstruation.
  • Sexual activity.
  • Foreign bodies.
  • Radiation.
  • Kidney and prostate biopsies.
  • Cancer.
  • Kidney injury from accidents or blow or sports.
  • Medications for cancer or anticoagulants, such as aspirin or blood thinners.
  • Exercise, although rare, can also lead to blood in the urine.
  • Sickle cell anaemia.
  • Use of catheter for extended periods of time or traumatic catheterisation.
  • Stents in the ureter.

Risk factors

Risk factors help determine people who are prone to certain urinary conditions, which in turn, may lead to blood in the urine:

• Men older than 50 years complaining of blood in the urine due to an enlarged prostate gland.
• A positive family history of kidney cancers or kidney stones.
• A strong history of chronic bladder inflammation (cystitis) or lower urinary tract infections.
• History of gross blood in the urine.
• People on aspirin; painkillers; blood thinners; or antibiotics, including penicillin have a high risk of kidney and urinary bleeding.
• Long distance runners or persons who work out rigorously are prone to exercise-induced blood in the urine.
• Exposure to chemicals and dyes increases the risk of urinary tract cancers.

There are several measures that can be taken to decrease the risk of urinary conditions. These include:

• Drink plenty of fluids
  An intake of 10 to 12 glasses of water daily helps flush out bacteria and other toxins during urination.
• Urinate when needed
  It is best not to delay the urge to urinate, as holding the urine for too long will pool the bacteria, leading to infections.
• Urinate after sexual activity
  Emptying the bladder immediately after intercourse will flush out the bacteria from the urethra, decreasing the risk of infections.
• Maintain hygiene of the genital area
  After urination or defecation, clean the area from front to back to prevent the re-entry of bacteria into the urethra.

It is important to find out the underlying cause of the presence of blood in urine. To do this, your doctor will carry out various diagnostic tests, which include:

• Medical History and Physical Examination
  This includes a complete medical history, including past and family history, along with a detailed physical examination.
• Blood Examination
  Blood tests can reveal the presence of infections if the white blood cell count is increased. Besides this, it may also reveal the presence of bacteria that have spread into the bloodstream and have led to a condition known as sepsis. Presence of chemical compounds such as calcium and uric acid, can reveal gout and kidney stones. The levels of a specific protein called prostate-specific antigen are elevated in the enlargement, infection, or cancer of the prostate gland.
• Urine Examination
  A urine examination and culture will check for blood cells, pus cells, other bacteria, and minerals, which can help diagnose conditions, such as UTIs and kidney stones. Sometimes a 24-hour urine sample may also be required to check for stones. Before further investigations are performed, it is advised that at least 2 out of 3 samples should show the presence of red cells over 3 weeks of examination.
• Urine Culture
  Along with a urine examination, a urine culture test would help determine the bacteria causing the infection to enable appropriate treatment initiation.
• Cystoscopy
  A cystoscopy is an examination to visualise the urethra and bladder. An instrument called cystoscope is used to check for stones or recurrent infections.
• Imaging Studies
  Studies, such as ultrasonography, magnetic resonance imaging (MRI), and computed tomography (CT) scan can detect kidney stones, tumours, or small masses within the urinary system.
• Biopsy
  Occasionally, doctors may perform a biopsy, wherein a small tissue sample is collected to look for advanced stages of kidney diseases or cancers.

People in whom the cause of blood in the urine cannot be determined, further specific investigations may be conducted to rule out malignancies.

Treatment

• Medication
  For uncomplicated infections, a short course of antibiotics is prescribed. Sometimes, painkillers are prescribed to relieve pain and burning while urinating along with antibiotics. In some conditions, a low dose of antibiotics for 6 months is given. In postmenopausal women, hormone oestrogen therapy might also be given.
• Surgery
  Surgery may be carried out in people who do not respond well to antibiotics and other medications. Procedures to remove larger kidney stones, blockages and tumours may be performed.

Lifestyle management

The following tips can help ease the discomfort a person may experience with their urinary conditions:

• Stay hydrated
  Drinking adequate amounts of water or 10 to 12 glasses daily is recommended to keep the urine diluted and remove toxins.
• Use heating pads
  A heating pad will ease the discomfort or pain in the bladder region.
• Avoid caffeine and other stimulants
  Caffeine or alcohol can irritate the bladder and increase the urge to urinate; hence, it is best to avoid them until the infection is treated completely.
• Opt for a healthy diet
  A balanced diet consisting of fresh fruits and vegetables should be encouraged. Fatty foods and fried items, lead to obesity, which is linked to prostate diseases.
• Try herbal supplements
  Certain herbal products, such as ryegrass and cranberry juice, may help in reducing urinary infections. Before beginning on herbal supplements, it is best to take the advice of the doctor.

Prognosis

The outcome of blood in urine depends on the underlying cause. Mild urinary infections can be treated with a course of antibiotics and resolve faster than long-term infections. The outcome of kidney stones will be better than that of kidney or bladder cancers.

Complications

The complications associated with conditions leading to blood in the urine are as follows:

• Recurrent UTIs.
• Chronic bladder dysfunction.
• Prostate cancer.
• Metastasis (the spread of cancer to other organs).
• Bladder obstruction.
• Hydronephrosis (abnormal dilatation of the tubes of the kidney due to back pressure created by the kidney stones or a tumour or an obstruction).