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Oganes E. Dilanyan
Urologist, MD, PhD

Blood in the urine

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In this article

Blood in urine or haematuria - is a dangerous symptom of a number of conditions affecting the urinary system. This symptom is especially dangerous in the absence of any pain because painless haematuria can often be a symptom of bladder or kidney cancer.

Causes of blood in the urine in men and women

There are nearly  170 causes of haematuria  and most of them are benign. Haematuria in women can be caused by cystitis or connected to a monthly period and in men it can be cause by prostatitis, prostatic hypertrophy or damage to the urethra. Even nephroptosis (also called floating kidney) can lead to haematuria. Other causes of haematuria include glomerulonephritis and eruption of a renal cyst into the renal pelvis. Kidney or ureter stones can often cause haematuria, and sometimes something as simple as taking an aspirin can lead to blood in the urine. 

But cancer can also be the cause of haematuria in men and women. Especially if there is no pain, or if an otherwise seemingly healthy person suddenly appears to have urine that is very bloody. In official medical documents urine appearance in the presence of bladder cancer is described as rather bloody. Appearance of worm-like clots indicates that the tumour had damaged a blood vessel in the kidney, which it turn caused the blood to get into the ureter and clotted there.

A common story of blood in the urine

... — Come on doctor, it is all just rubbish! Is blood in the urine really such a big deal that I need to drop everything and run to you? Just tell me what I can take to turn my urine back to its normal colour. I have 5 business meetings tomorrow! And then I am going away for two months. Besides, my urine isn’t even red any more, only the urine test shows the presence of blood….
— And then you, Ivan, will come back to me with a diagnosis of “inoperable bladder cancer” or “4th stage kidney cancer” and I will have to write in your medical notes that “the doctors council had concluded that nothing could be done for the patient and the only thing that can be offered is symptomatic pain relief”. 
I was saying this in a very business-like and dry manner. I am rarely like this but this particular person was known (and thank God is still known) for being extremely stubborn. There was no way I could calmly explain anything to him or persuade him, the worst thing is he is a former doctor. He is not a urologist and has been working in administration for many years but still, how many times have we all heard these words while still studying: “If you see any blood in the urine look for a tumour”. And then I though, if a medic asks for a pill to turn their urine back to its original colour, would an ordinary patient be concerned if they noticed blood in their urine?  

“I have realised that syphilis was so frightening here due to the fact that it was not frightening”
M.A. Bulgakov “A young doctor’s notebook”

Will a patient be concerned upon seeing blood in their urine?

No, they won’t be. Half of them will think “well, probably just cystitis”. My well serving memory immediately throws up so many cases where a terminally ill patient with metastasised cancer in their bones and in need of narcotics for pain relief when asked “Did you notice any blood in the urine?” answered: “Yes, about 7-8 months ago” … “And who did you go and see then?”
—  No one. I checked the internet and found that a pill can help get rid of the blood and just took it and it went away. 
They could have been saved had they seen a doctor earlier.

“Every intelligent person should know the colour of their urine!”
Words allegedly said by Professor Z. Vineberg

What does blood in the urine mean in the absence of pain

Unfortunately, over half the cases of pain free blood in the urine have something to do with  urinary system cancers. A growing tumour damages the blood vessels of the kidney or the bladder and sometimes the blood vessels of the ureter. If the patient ignores this symptom the bleeding will most likely stop eventually. And when blood appears in the urine again it will probably be too late to do anything by that point. So, haematuria and erythrocyturia should both be taken very seriously. It is a symptom that requires urgent diagnosis. 
... And unfortunately, I was not concerned about my patient Ivan for nothing. Although we were not too late to diagnose him and his tumour did not have time to spread beyond the bladder. Of course, he never got to go on his business trip as he was on the operating table at the time but he got to keep his bladder and only the tumour was removed. And he got to keep his life.

“What to do?”
N. Chernyshevsky

Detailed diagnosis of haematuria causes

Go see a doctor. Quick, Complete diagnosis procedure in the presence of blood cells in the urine includes: general urine test, urine culture, detailed ultrasound scan, CFM (colour flow mapping) of the urinary system and often cystoscopy.  The latter allows to locate the source of bleeding in the bladder or the urethra and perform a bladder biopsy. In the presence of certain symptoms additional tests may include a CT or MRI scan.

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