Haematuria is defined as the presence of red blood cells in the urine. “Frank” haematuria refers to a discolouration of the urine due to blood that can be seen with the naked eye. When blood is not visible but detected when urine is examined under the microscope, it is referred to as “microscopic haematuria”.
Haematuria can originate from any site in the urinary tract. Studies have shown that microscopic traces of blood can be seen in up to 10% of the population. In the majority of cases, no sinister cause is found. In many cases, despite extensive investigations, no specific cause is found at all. This is particularly the case in young, otherwise healthy individuals with microscopic haematuria. Despite this, all cases of haematuria are taken seriously and should be thoroughly investigated to ensure that no sinister cause is missed.
Common Causes of Haematuria
- Idiopathic (No cause found)
- Urinary tract infections
- Intense exercise
- Stone disease
- Kidney disease (eg. Damage due to diabetes, nephritis)
- Benign Prostate Enlargement
- Bladder cancer
- Kidney cancer
- Prostate cancer
Every patient with haematuria must undergo a few basic investigations as a minimum to rule out a sinister cause for the blood in the urine. Precisely which tests will be required will be a decision made by your doctors depending on your age, risk factors and the degree of bleeding. Even if no serious cause is discovered, follow-up is required, usually by your general practitioner. This usually consists of periodic urine tests.
Possible tests that may be required after haematuria is discovered
- Urine culture. To rule out infection
- Urine cytology. Looking for cancer cells in the urine
- 24 Hour Urine test. Looking for signs of excessive protein in the urine, possibly indicating kidney disease
- Blood tests. Kidney function tests
- Ultrasound of the urinary tract
- CT scan of the urinary tract
- Cystoscopy. A direct telescopic examination of the bladder to identify polyps or cancers
- Kidney biopsy. If kidney disease is suspected
Interstitial Cystitis/Painful Bladde
Interstitial cystitis (IC), also known as painful bladder syndrome (PBS) is a chronic bladder condition.
The condition is characterised by the following predominant symptoms:
- Pain in the bladder area (above the pubic bone, in the lower abdomen) or in the pelvic or perineal region, especially related to filling of the bladder.
- Urinary frequency, urgency and nocturia (the need to wake from sleep to pass urine)
The condition mainly affects females with men accounting for 10-20% of all cases.
Whilst the symptoms of IC/PBS are most commonly seen in patients suffering from an acute urinary tract infection, patients with IC/PBS have often had multiple urine tests, each showing no sign of infection. In addition, patients have received multiple courses of antibiotics without effect. Many patients with IC/PBS can link exacerbations of the symptoms to certain foods or unusual stress.
Causes of Interstitial Cystitis
Several theories have been postulated to explain the cause(s) of IC/PBS. It is likely that IC/PBS is the result of a combination of the following abnormalities:
- Breakdown of the protective lining of the bladder allowing irritants in the urine to penetrate the bladder wall
- Excess release of chemicals that promote inflammation within the bladder wall
- An abnormality of the nerves that sense bladder fullness
- An autoimmune process attacking the bladder
Diagnosing Interstitial Cystitis
No single test has proven to be completely accurate in the diagnosis of IC/PBS. The following are usually used in combination to make the diagnosis:
History and physical examination.
The key elements in the history are the presence of the following:
- Some kind of suprapubic discomfort (pain, pressure etc) worse when the bladder is full and relieved when the bladder empties.
- Urinary frequency and a degree of urinary urgency. Interestingly, these symptoms often improve during the menstrual period.
Patients with IC/PBS are more likely to suffer from other conditions including irritable bowel syndrome, chronic fatigue and fibromyalgia.
Patients with IC/PBS may also suffer from pelvic floor dysfunction. Symptoms of this condition include
- Pelvic pain and tenderness on palpation of pelvic floor muscles.
- Urinary frequency
- Pain with intercourse or with ejaculation
- Variable urinary flow rate
Other important investigations
- Urine tests to exclude infection and sinister causes for bladder irritation such as cancer
- Cystoscopy +/- bladder biopsy to look for well-described signs of IC and to exclude other rarer causes of bladder pain and frequency (eg bladder cancer). Cystoscopic findings may be normal in up to 1/3 patients with symptoms of IC/PBS.
- Urodynamic studies (not necessary in most cases)
Several treatments are available to improve the symptoms of IC/PBS. Unfortunately, despite extensive research, no single agent has proven to be effective in all patients. Most patients will require a trial of 2 or more agents. Despite an initial response, many patients will ultimately relapse and repeated treatment is often necessary.
- Lifestyle modification. Avoid foods that irritate your bladder. Examples may include caffeine, spicy foods, alcohol. It is very important to avoid constipation. Flaxseed oil tablets have been used with success in many patients.
- Pelvic floor physiotherapy may help some patients, especially those with symptoms of pelvic floor dysfunction.
- Amitryptyline (Endep). A tricyclic anti-depressant, Endep at low doses is often effective due to a complex mechanism of action including analgesic and antihistamine effects. Side effects include constipation and tiredness. Weight gain may also be an issue for some patients.
- Anti-histamines. By blocking release of the powerful inflammatory agent histamine,drugs such as Hydroxyzine and Cimetidine are effective in about 30% of patients.
- Elmiron (pentosan polysulfate). This agent works by reinforcing the inner lining of the bladder, thereby helping to prevent irritants from entering the bladder wall. Side effects include diarrhoea and nausea. Alopecia has also been reported in 3-4% of patients.
- Intravesical DMSO. Directly placed into the bladder once a week for six to eight weeks. This agent appears to reduce inflammation within the bladder and possibly removes free radicals that can damage the bladder lining. The main side effect is a garlic-like odour that lasts for several hours after treatment. Initially the symptoms may deteriorate but after 2-3 treatments the symptoms begin to improve.Some researchers use a combination of DMSO. Heparin and Triamcinolone (40mg) and sodium bicarbonate.
- Bladder Hydrodistention. Gentle stretching of the bladder on a periodic basis may improve symptoms in the short term over a 1-3 month period. It almost always needs to be repeated.
Other less-commonly used treatments:
- Intravesical Chlorpactin
- Intravesical local anaesthetics (mixture of Lignocaine Jelly and Bupivicane). Remarkable short-term clinical improvements have been reported with this treatment. It may also be combined with steroids.
- Intravesical BCG
- Anti-seizure medications. These include Gabapentin and Pregabalin. They should be used only under the supervision of a dedicated pain management clinic.