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Understanding Haematuria – Your Complete Guide

Have you noticed blood in your urine? Whether it's a visible colour change or something detected on a routine test, this discovery can be genuinely alarming. You're not alone in feeling concerned, and that anxiety is completely understandable. This comprehensive guide will help you understand what haematuria means, why it happens, and what steps you should take next.

1.1 What Is Haematuria? – The Simple Explanation

Haematuria simply means the presence of blood in your urine. It's a sign—not a disease itself—much like a warning light on your car's dashboard. The light indicates something needs attention, but doesn't tell you exactly what the problem is.

Blood in your urine indicates bleeding somewhere along your urinary tract—the sophisticated system comprising your kidneys, ureters (the tubes connecting kidneys to the bladder), bladder, and urethra (the tube through which urine exits your body).

The good news? While discovering blood in your urine can be worrying, many causes are entirely treatable. What matters most is getting the right investigation promptly so we can identify the specific cause and ensure you receive appropriate care.

2: What Causes Blood in Urine?

2.1 Common Causes – The Simple Explanation

Haematuria can arise from many different conditions affecting any part of your urinary tract. Here are the most common causes we see in clinical practice:

CHAPTER 3: Understanding Your Risk

3.1 Who Is Most at Risk? – The Simple Explanation

While anyone can develop haematuria, certain factors increase the likelihood that blood in your urine might indicate a serious underlying condition. Understanding your personal risk profile helps determine how urgently you should be investigated.

The main risk factors to consider include:

1. 1. Age: Risk increases significantly after age 40-50, with peak incidence in the 60s, 70s, and 80s
2. 1. Smoking history: Current or past smoking is a major risk factor for both bladder and kidney cancer
3. 1. Type ofhaematuria:  Visible blood carries higher risk than microscopic haematuria
4. 1. Gender: Men have higher rates of bladder and kidney cancer
5. 1. Occupational exposure: Certain chemicals used in dye, rubber, and paint industries increase bladder cancer risk
6. 1. Previous pelvic radiotherapy: Can increase long-term bladder cancer risk

⚠️ Higher Risk Combination: If you are over 60, have a smoking history, AND have visible haematuria, you have a significantly elevated probability of underlying malignancy (approximately 30-40% in some studies). This combination mandates urgent, comprehensive investigation.

Lower risk individuals: If you're under 40, have never smoked, and have only microscopic haematuria without other symptoms, your risk of serious pathology is very low. However, investigation is still generally recommended to exclude other causes like stones or kidney disease.

Haematuria Diagnostic Guide: Restructured Content

GGO Med | Mr Giangiacomo Ollandini

SECTION 3: Understanding Your Individual Risk Factors

Layperson Tier

Why Risk Factors Matter

When I see a patient with blood in their urine, one of my first priorities is understanding their individual risk profile. Not everyone with haematuria faces the same likelihood of a serious cause—and knowing your specific risk factors helps me decide how urgently we need to investigate and which tests are most important for you.

Let me be clear: finding blood in your urine doesn't mean you have cancer. Most cases have benign explanations. However, certain factors do increase the chance that we might find something more serious, particularly bladder or kidney cancer. Understanding these helps us work together to get you the right investigations at the right pace.

The Key Risk Factors I Assess

[CARD GRID: 6 Risk Factor Cards]

Card

Title

Simple Explanation

1

Age

Risk increases significantly after 50. Whilst bladder cancer can occur in younger people, it becomes much more common in your 60s, 70s, and 80s.

2

Smoking History

This is one of the biggest factors I look at. If you smoke or used to smoke, your risk of bladder and kidney cancer is 2-4 times higher than a non-smoker.

3

Type of Bleeding

Visible blood (that you can see) carries a higher risk than microscopic blood (only found on a test). About 15-20% of people with visible haematuria have bladder cancer.

4

Being Male

Men have higher rates of bladder and kidney cancer than women—partly due to historically higher smoking rates, but other factors play a role too.

5

Work History

Certain jobs involving chemicals (dyes, rubber, paints, petroleum) increase bladder cancer risk, sometimes decades after exposure.

6

Previous Treatments

Radiotherapy to the pelvis or certain chemotherapy drugs can increase long-term bladder cancer risk.

How I Use This Information

I combine all your risk factors to build a complete picture. This determines two things:

1. 1. How urgently we need to investigate
2. 1. How extensively we need to test

[INTERACTIVE ELEMENT: Risk Profile Examples]

Higher-Risk Example: A 68-year-old man who has smoked for 40 years and notices visible blood in his urine. This combination means comprehensive, urgent investigation—typically within two weeks on the NHS suspected cancer pathway.

Lower-Risk Example: A 28-year-old non-smoking woman with microscopic haematuria found on a routine health check. The likelihood of cancer is much lower (though not zero), so we can be slightly more measured whilst still being thorough.

Important: Lower risk never means "no investigation needed." It simply means we can tailor our approach whilst remaining careful. I've seen cancer in young, healthy patients with no obvious risk factors—it's rare, but it happens.

<details> <summary><strong>Deep Dive: The Evidence Behind Risk Stratification</strong></summary>

Clinical Evidence and Guidelines

The risk factors I assess are based on large population studies and evidence-based clinical guidelines, including NICE guidance in the UK, European Association of Urology (EAU) guidelines, and American Urological Association (AUA) recommendations.

Age as a Risk Factor

The incidence of urological cancer rises sharply from age 50 onwards:

• • Peak incidence occurs in the 60s, 70s, and 80s
• • Age over 45-50 years is considered a significant threshold in haematuria assessment
• • However, even younger patients warrant investigation—the threshold simply determines urgency

Smoking: The Numbers

Smoking is the most important modifiable risk factor:

• • Bladder cancer risk: 2-4 times higher in smokers
• • Dose-response relationship: Risk correlates with pack-years (packs per day × years smoked)
• • After cessation: Risk decreases but remains elevated for 15-20 years
• • Former heavy smokers: May still carry significant risk decades later

When taking your history, I ask specifically about:

• • When you started smoking
• • When (if) you stopped
• • Roughly how many cigarettes per day
• • Any periods of heavier or lighter smoking

Haematuria Type: The Statistics

The prevalence of underlying malignancy differs significantly:

Type

Cancer Prevalence

Visible (macroscopic) haematuria

15-20%

Microscopic haematuria

2-5% (depending on other risk factors)

This substantial difference explains why visible haematuria typically triggers more urgent and comprehensive investigation.

Occupational Exposures in Detail

Bladder cancer has well-established links to occupational chemical exposure:

High-risk industries (historical and current):

• • Dye manufacturing
• • Rubber industry
• • Leather and tanning
• • Printing
• • Petroleum and chemical processing
• • Paint manufacturing
• • Hairdressing (certain dyes)

Key chemicals:

• • Aromatic amines (beta-naphthylamine, benzidine, 4-aminobiphenyl)
• • Polycyclic aromatic hydrocarbons
• • Certain solvents

Critical point: The latency period between exposure and cancer development can be 20-40 years. This is why I take a complete occupational history, not just your current job.

Previous Pelvic Radiotherapy

Radiotherapy for other pelvic cancers increases long-term bladder cancer risk:

• • Typically appears many years (10-20+) after treatment
• • Applies to radiotherapy for prostate, cervical, rectal, and other pelvic cancers
• • The radiation field determines which structures are at increased risk

Chronic Bladder Irritation

Long-term irritation can slightly increase risk, particularly for squamous cell carcinoma (a rarer bladder cancer subtype):

• • Long-term indwelling catheters
• • Recurrent urinary tract infections over many years
• • Bladder stones causing chronic irritation
• • Schistosomiasis (bilharzia) infection—relevant if you've lived in or visited endemic areas

Medication-Related Risks

Certain medications increase urological cancer risk:

Cyclophosphamide:

• • A chemotherapy and immunosuppressive drug
• • Associated with increased bladder cancer risk
• • Risk depends on cumulative dose

Phenacetin:

• • An analgesic now withdrawn from the market
• • Prolonged high-dose use was linked to kidney problems and upper tract urothelial cancer
• • Historical exposure still relevant in older patients

Family History and Genetics

Most urological cancers are not strongly hereditary, but certain factors increase risk:

• • Strong family history of urological cancers
• • Lynch syndrome (hereditary non-polyposis colorectal cancer syndrome)—increases upper tract urothelial cancer risk
• • Von Hippel-Lindau disease—increases kidney cancer risk
• • Other rare genetic syndromes

Combining Multiple Risk Factors

Risk factors don't simply add together—they multiply. A patient with:

• • Age over 60
• • 30+ pack-year smoking history
• • Visible haematuria
• • Previous occupational chemical exposure

...has a substantially higher probability of malignancy than each factor would suggest individually. This guides both urgency and extent of investigation.

Risk Stratification in Practice

Modern guidelines typically stratify patients into:

• • High risk: Urgent, comprehensive investigation (CT urogram + cystoscopy within 2-week suspected cancer pathway)
• • Intermediate risk: Prompt investigation with full imaging and cystoscopy
• • Low risk: Investigation still recommended, but may be less urgent; tailored based on individual factors

The goal is ensuring those at highest risk receive the fastest, most comprehensive workup whilst avoiding over-investigation of those at genuinely low risk.

</details>

Key Takeaways

[SUMMARY CARD]

✓ Age, smoking history, and visible bleeding are the major risk factors for underlying cancer

✓ Male gender, occupational exposures, and previous pelvic radiotherapy also increase risk

✓ Multiple risk factors together significantly elevate the probability of serious findings

✓ Lower risk doesn't mean "no investigation"—it means a tailored approach

✓ Risk assessment helps ensure the right people get the fastest, most thorough workup

[CTA BANNER] Concerned about blood in your urine? Understanding your risk factors is the first step. Book a consultation to discuss your individual situation.

SECTION 4: The Diagnostic Pathway

Layperson Tier

How I Investigate Haematuria

When you come to see me about blood in your urine, I follow a structured, step-by-step process. This approach is designed to be both thorough (so we don't miss anything important) and efficient (so you're not having unnecessary tests or delays).

Let me walk you through exactly what happens at each stage.

Step 1: Our Consultation

[ICON: Conversation/Consultation]

Everything starts with a detailed conversation. I'll ask you comprehensive questions because the answers often point us towards likely causes and help me plan the right investigations.

Questions I'll ask about the blood itself:

• • When did you first notice it?
• • Does it happen every time you urinate, or just sometimes?
• • What colour is your urine—pink, red, brown, cola-coloured?
• • Have you passed any blood clots? If so, how big and how often?
• • Does the blood appear at the start, throughout, or at the end of urination?
• • Is there any pain associated with it?

Other important questions:

• • Any changes to how often you urinate, urgency, burning sensation, or weak stream?
• • Any pain in your side, abdomen, or back?
• • Have you had any fever, unexplained weight loss, or feeling generally unwell?
• • What medications do you take (especially blood thinners)?
• • Your smoking history—I'll ask for details
• • Your work history—some jobs carry increased risk
• • Any family history of kidney or bladder problems?
• • For women: could menstruation be a factor?

Physical examination: I'll also examine you—feeling your abdomen for any kidney enlargement or tenderness, checking your blood pressure, and for men, a digital rectal examination to assess the prostate.

Step 2: Urine Tests

[ICON: Test Tube/Sample]

These are fundamental baseline tests that I arrange for everyone with haematuria.

Urine dipstick: A quick bedside test that confirms blood is present and checks for signs of infection, protein (which might suggest kidney disease), and other markers.

Urine microscopy, culture and sensitivity: Your sample goes to the laboratory where specialists examine it under a microscope. This tells us:

• • How many red blood cells are present
• • Whether the bleeding looks like it's coming from the kidneys or lower urinary tract
• • If there's any infection, and which antibiotics would treat it

Urine cytology (in selected cases): This specialist test looks specifically for abnormal or cancerous cells in your urine. It's particularly useful for detecting high-grade bladder cancer and a flat, aggressive form called carcinoma in situ (CIS). I typically request this for higher-risk patients.

Step 3: Blood Tests

[ICON: Blood Drop/Vial]

Blood tests provide essential context about your overall health and kidney function.

Kidney function tests: These measure how well your kidneys are working. This is important because:

• • Impaired kidney function might point towards kidney disease
• • We need to check kidney function before certain scans (the contrast dye used can affect kidney function in some people)

Full blood count: Checks for anaemia (low blood count from chronic bleeding) and signs of infection.

PSA test (for men): I'll discuss PSA testing with my male patients. PSA is primarily a marker for prostate problems, and whilst prostate issues don't usually explain haematuria directly, it's often sensible to check as part of a comprehensive assessment. I'll explain the benefits and limitations so you can make an informed decision.

Step 4: Imaging Scans

[ICON: CT Scanner/Imaging]

Imaging allows us to see the structure of your kidneys, ureters (the tubes connecting kidneys to bladder), and bladder without any invasive procedures.

Ultrasound scan: Uses sound waves to create images. It's completely safe, involves no radiation, and is excellent for assessing kidney size and structure. However, it can miss smaller problems, particularly in the ureters.

CT urogram: This is the gold-standard imaging test for haematuria investigation, especially for higher-risk patients or visible haematuria. It provides exceptionally detailed images and is highly sensitive for detecting tumours, stones, and structural abnormalities anywhere in the urinary tract.

I'll explain more about these scans in the next section.

Step 5: Cystoscopy

[ICON: Camera/Scope]

Cystoscopy means looking directly inside your bladder using a thin telescope with a camera. This is the definitive way to check the bladder lining for tumours, inflammation, stones, or other abnormalities.

Flexible cystoscopy: The standard outpatient procedure, done awake in clinic using local anaesthetic gel. Most patients find it much more comfortable than they expected.

Rigid cystoscopy: If we find something suspicious, a rigid cystoscopy under anaesthetic allows us to take samples (biopsies) or remove abnormal tissue for testing.

I'll explain cystoscopy in detail in Section 6.

How I Tailor This to You

[VISUAL: Branching Pathway Diagram]

Not everyone needs every test. I tailor the pathway based on:

• • Your risk factors: Higher-risk patients have comprehensive, urgent investigation
• • Type of haematuria: Visible blood generally triggers more extensive testing
• • Initial test results: If urine tests suggest the bleeding is from kidney disease rather than cancer, I might refer you to a kidney specialist
• • Your medical history: Allergies to contrast dye or pre-existing kidney problems may influence which scans we use
• • NHS vs Private: The pathway is similar, but timing may differ. Private investigation often proceeds more rapidly.

<details> <summary><strong>Deep Dive: Clinical Reasoning and Detailed Protocols</strong></summary>

The Consultation: What I'm Looking For

History-Taking in Detail

The medical history provides crucial diagnostic clues:

Timing and pattern of haematuria:

• • Intermittent vs constant bleeding
• • Relationship to urination timing (initial, terminal, or throughout)
• • Duration and progression

Timing within the urinary stream:

• • Initial haematuria (blood at the start): Suggests urethral or prostatic origin
• • Terminal haematuria (blood at the end): Suggests bladder neck or trigone origin
• • Total haematuria (throughout): Suggests bladder or upper tract origin

Associated symptoms:

• • Irritative symptoms (frequency, urgency, dysuria): May suggest infection, stones, or bladder cancer
• • Obstructive symptoms (hesitancy, weak stream, incomplete emptying): May suggest BPH or bladder neck problems
• • Systemic symptoms (weight loss, fatigue, night sweats): Red flags for malignancy
• • Flank pain: May suggest stones or renal pathology

Clot characteristics:

• • Clots suggest significant bleeding
• • Clot shape can indicate origin: "Worm-like" clots suggest upper tract origin (formed in ureter)

Physical Examination Techniques

Abdominal examination:

• • Kidney palpation (balloting technique)
• • Checking for masses, tenderness, organomegaly
• • Suprapubic palpation for bladder distension

Digital rectal examination (DRE) in men:

• • Prostate size assessment
• • Consistency (firm, nodular, or boggy)
• • Presence of nodules (cancer concern)
• • Tenderness (prostatitis)

General assessment:

• • Blood pressure (hypertension associated with kidney disease)
• • Signs of anaemia (pallor, tachycardia)
• • Peripheral oedema (kidney disease)
• • Lymphadenopathy

Urine Tests: Technical Details

Dipstick Interpretation

The urine dipstick detects haem (the iron-containing part of haemoglobin) rather than intact red blood cells. Results are typically reported as:

• • Trace, 1+, 2+, 3+ (increasing concentrations)

Important considerations:

• • False positives: Myoglobinuria, haemoglobinuria, dehydration, certain medications
• • False negatives: High-dose vitamin C, dilute urine
• • Dipstick alone cannot distinguish between haematuria, haemoglobinuria, and myoglobinuria

Microscopy: Red Cell Morphology

Urine microscopy with phase-contrast can distinguish:

Dysmorphic red blood cells:

• • Irregular, distorted shapes
• • Suggest glomerular (kidney filtering unit) origin
• • Associated with kidney diseases like IgA nephropathy

Isomorphic (normal-shaped) red blood cells:

• • Uniform, biconcave appearance
• • Suggest lower urinary tract origin (bladder, prostate, urethra)
• • More likely to indicate stones, infection, or malignancy

Red cell casts:

• • Red cells clumped together within a protein matrix
• • Almost pathognomonic (diagnostic) of glomerular disease
• • Require nephrology referral

Urine Cytology: Role and Limitations

Strengths:

• • High specificity for high-grade urothelial carcinoma (95%+)
• • Excellent for detecting carcinoma in situ (CIS)
• • Non-invasive screening tool

Limitations:

• • Low sensitivity for low-grade tumours (10-50%)
• • Requires adequate cell numbers and good-quality specimen
• • Inter-observer variability in interpretation
• • False positives with instrumentation, infection, stones, or intravesical therapy

When I request it:

• • Visible haematuria with risk factors
• • High-risk patients (smokers, age >50, occupational exposure)
• • Surveillance of patients with previous bladder cancer
• • When initial cystoscopy is equivocal

Blood Tests: Clinical Context

Renal Function Assessment

Serum creatinine and eGFR:

• • eGFR (estimated glomerular filtration rate) calculated from creatinine, age, sex, and ethnicity
• • Normal eGFR: >90 mL/min/1.73m²
• • Stages of chronic kidney disease defined by eGFR thresholds

Why it matters for investigation:

• • CT contrast is nephrotoxic in patients with severely impaired function
• • eGFR <30: CT contrast generally avoided
• • eGFR 30-60: Proceed with caution, adequate hydration, consider alternatives

PSA Considerations

PSA (prostate-specific antigen) discussion in haematuria:

Factors that elevate PSA (not cancer):

• • Benign prostatic hyperplasia (BPH)
• • Urinary tract infection
• • Recent catheterisation or urological instrumentation
• • Recent ejaculation
• • Prostatitis
• • Digital rectal examination (minimal effect)
• • Vigorous cycling

My approach:

• • Discuss PSA testing with informed consent
• • Ideally delay if recent UTI or instrumentation
• • Interpret in clinical context
• • Raised PSA requires further investigation (typically MRI prostate) but doesn't explain haematuria itself unless advanced cancer is present

The Two-Week Wait Pathway

For higher-risk patients with suspected urological cancer, the NHS operates a "two-week wait" (2WW) urgent referral pathway:

Referral criteria (NICE NG12):

• • Age ≥45 with unexplained visible haematuria without UTI, or
• • Age ≥45 with visible haematuria persisting/recurring after UTI treatment, or
• • Age ≥60 with unexplained microscopic haematuria and either dysuria or raised white cell count

What this means for patients:

• • First appointment within 14 days of referral
• • Comprehensive investigation (typically CT urogram + cystoscopy)
• • Fast-track pathway to expedite diagnosis

Clinical Example: Diagnostic Reasoning

Mrs Evans, 65, former smoker

Presentation: One episode of cola-coloured urine

Risk assessment:

• • Age over 50: ✓ (increased risk)
• • Smoking history: ✓ (significant risk factor)
• • Visible haematuria: ✓ (higher risk than microscopic)
• • Male gender: ✗
• • Occupational exposure: Not identified

Conclusion: High-risk profile → Urgent investigation via suspected cancer pathway

Investigation sequence:

1. 1. Urine dipstick: Confirmed blood, no infection
2. 1. Urine microscopy: Normal red cell morphology (isomorphic), no casts
3. 1. Kidney function: Normal (eGFR 78) - safe for CT contrast
4. 1. CT urogram: No kidney or ureteric lesions, no stones, bladder appears unremarkable
5. 1. Flexible cystoscopy: Small papillary (frond-like) lesion on left lateral bladder wall

Next step: Rigid cystoscopy under anaesthetic with TURBT (transurethral resection of bladder tumour) for tissue diagnosis and staging

Learning points:

• • CT urogram alone would have missed this bladder lesion
• • This illustrates why both imaging AND cystoscopy are necessary
• • Risk factors correctly predicted the need for comprehensive investigation

</details>

The Diagnostic Pathway: Key Steps

[SUMMARY INFOGRAPHIC]

1. 1. Consultation → Detailed history, examination, risk assessment
2. 1. Urine tests → Dipstick, microscopy, culture, +/- cytology
3. 1. Blood tests → Kidney function, full blood count, +/- PSA for men
4. 1. Imaging → Ultrasound or CT urogram depending on risk
5. 1. Cystoscopy → Direct visualisation of the bladder lining
6. 1. Results discussion → Diagnosis and management plan together

SECTION 5: Focus on Imaging

Layperson Tier

Seeing Inside Your Urinary System

Imaging scans allow me to visualise your kidneys, ureters, and bladder without any surgical procedure. Think of it as taking detailed photographs of your internal plumbing. There are two main types I use for haematuria investigation.

Ultrasound Scan

[ICON: Ultrasound Probe]

What it is: An ultrasound uses sound waves (the same technology used to image babies during pregnancy) to create pictures of your organs. It's completely painless and involves no radiation.

What happens: You'll be asked to arrive with a full bladder. The sonographer (scanning specialist) applies some gel to your skin and moves a handheld device over your kidney and bladder areas. After we've imaged your full bladder, you'll empty it, and we scan again to see how well your bladder empties.

The whole appointment takes about 15-20 minutes.

What it's good at:

• • Checking kidney size and structure
• • Finding larger kidney masses or cysts
• • Detecting significant bladder wall thickening or large tumours
• • Measuring how much urine remains after you empty your bladder

Limitations:

• • Can miss smaller tumours, particularly in the ureters
• • Image quality can be affected by body size or bowel gas
• • Less detailed than CT scanning

When I use it:

• • As an initial test for lower-risk patients
• • When CT contrast dye isn't suitable (kidney problems or allergies)
• • For pregnant women (no radiation)

CT Urogram

[ICON: CT Scanner]

What it is: CT urography is considered the gold-standard imaging test for haematuria, especially for higher-risk patients or visible haematuria. It uses X-rays and a special contrast dye injected into your vein to create exceptionally detailed images of your entire urinary tract.

Why it's the gold standard:

• • Highly accurate for detecting even small tumours anywhere in the urinary tract
• • Excellent at visualising the ureters (the tubes connecting kidneys to bladder)—this is critically important because cancer in these tubes is often missed on ultrasound
• • Brilliantly clear for detecting kidney and ureteric stones
• • Provides comprehensive anatomical information in one test

What happens: The scan is done in three phases:

1. 1. First scan (no contrast): Establishes a baseline and picks up any stones
2. 1. Second scan (shortly after contrast injection): Shows the kidney tissue in detail
3. 1. Third scan (several minutes later): Shows the contrast filling the collecting system, ureters, and bladder

When the contrast is injected, you'll feel a temporary warm flushing sensation spreading through your body—perhaps a metallic taste too. This is completely normal and passes within a minute or two.

The actual scanning takes only seconds for each phase, though the whole appointment is about 20-30 minutes.

Important Things to Know Before a CT Urogram

[CALLOUT BOX: Pre-Scan Checks]

Kidney function check: The contrast dye is filtered by your kidneys. If your kidney function is significantly impaired, the dye could potentially cause problems. I always check your kidney function with a blood test before arranging a CT urogram.

Allergy history: A small percentage of people have allergic reactions to the contrast dye—usually mild (hives, itching) but very rarely severe. I'll always ask about previous reactions to contrast or significant allergies. If you've had a reaction before, we may use a different type of scan or give you protective medication beforehand.

Radiation: CT scans use X-rays, which means a small radiation dose. Modern scanners keep this as low as possible, and the diagnostic benefit almost always far outweighs the tiny risk. However, it's something I consider, particularly for younger patients or during pregnancy.

What Happens After the Scan?

[FLOWCHART: Imaging Results Pathways]

Finding

What It Means

Next Steps

Clear scan

Reassuring, but doesn't fully exclude bladder problems

Cystoscopy still needed in most cases

Kidney or ureteric mass

Needs further assessment

Typically surgical planning

Bladder mass/thickening

Needs direct visualisation

Cystoscopy and likely biopsy

Stones

Explains the bleeding

Management depends on size and symptoms

Hydronephrosis (kidney swelling)

Something is blocking the drainage

Investigation to find the cause

Important point: Even when imaging looks completely normal, I usually still recommend cystoscopy. This is because flat lesions in the bladder (like carcinoma in situ) can be invisible on CT but clearly visible when I look directly inside.

<details> <summary><strong>Deep Dive: Imaging Modalities in Detail</strong></summary>

Ultrasound: Technical Aspects

How Ultrasound Works

Ultrasound imaging uses high-frequency sound waves (typically 3.5-12 MHz for urological imaging) that bounce off internal structures. Different tissues reflect sound differently, creating the grayscale image you see on screen.

Imaging modes:

• • B-mode (brightness mode): Standard grayscale imaging
• • Doppler: Detects blood flow—useful for assessing renal vasculature and varicoceles
• • Colour Doppler: Shows flow direction and velocity

Ultrasound Assessment Protocol

Kidney assessment:

• • Size measurement (normal adult kidney: 10-12 cm length)
• • Cortical thickness (normal: >10mm)
• • Echogenicity (brightness relative to liver/spleen)
• • Corticomedullary differentiation
• • Presence of masses, cysts, stones, or hydronephrosis

Cyst characterisation (Bosniak classification):

• • Simple cysts: Anechoic, smooth walls, through-transmission—benign
• • Complex cysts: May require CT characterisation and possible follow-up or intervention

Bladder assessment:

• • Wall thickness (normal: <3mm when distended)
• • Intraluminal masses or stones
• • Residual volume after voiding (normal: <50mL; abnormal: >100mL)

Strengths and Limitations

Strengths:

• • No ionising radiation
• • Real-time imaging
• • Portable and widely available
• • Cost-effective
• • No contrast required for basic assessment
• • Can be repeated frequently (e.g., monitoring)

Limitations:

• • Operator-dependent quality
• • Limited by body habitus, bowel gas, patient cooperation
• • Poor ureteric visualisation (unless dilated)
• • Lower sensitivity for small tumours (<3cm) compared to CT
• • Cannot reliably characterise complex renal masses
• • Limited field of view

When Ultrasound May Miss Pathology

Renal lesions:

• • Small solid tumours (<2cm) in certain locations
• • Iso-echoic tumours (same brightness as surrounding tissue)
• • Upper pole lesions obscured by ribs

Ureteric lesions:

• • Most ureteric tumours are not visible on ultrasound
• • Small stones may be missed
• • Strictures not directly visualised

Bladder lesions:

• • Flat lesions (CIS) not visible
• • Small papillary tumours may be missed
• • Lesions at dome or in diverticula

CT Urography: Technical Details

Protocol and Phases

CT urography typically consists of three phases:

1. Non-contrast phase (CT KUB):

• • Performed before contrast injection
• • Primary purpose: Stone detection (stones appear bright white)
• • Also establishes baseline kidney appearance
• • Identifies calcification in masses

2. Nephrographic (corticomedullary) phase:

• • Acquired 80-100 seconds after contrast injection
• • Contrast enhances kidney parenchyma
• • Optimal for detecting renal cell carcinoma
• • Shows enhancement patterns of renal masses

3. Excretory (urographic) phase:

• • Acquired 5-15 minutes after injection
• • Contrast excreted into collecting system, ureters, and bladder
• • Outlines the urothelium (lining of the urinary tract)
• • Optimal for detecting upper tract urothelial carcinoma (UTUC)
• • Shows filling defects, strictures, and bladder lesions

Radiation dose considerations:

• • Three-phase CT urography: Approximately 15-25 mSv effective dose
• • Split-bolus protocols can reduce dose whilst maintaining diagnostic accuracy
• • Modern dose-reduction techniques (iterative reconstruction) help minimise exposure

Why CT Urography is Superior for UTUC Detection

Upper tract urothelial carcinoma (UTUC)—cancer arising in the renal pelvis or ureter—is less common than bladder cancer but equally serious. CT urography is critical because:

• • Ultrasound rarely visualises the ureters adequately
• • The excretory phase shows filling defects (tumours appearing as gaps in the contrast-filled system)
• • CT can detect wall thickening, mass effects, and local invasion
• • Staging information (local extent, lymph nodes) obtained simultaneously

Detection rates:

• • CT urography sensitivity for UTUC: 92-96%
• • Ultrasound sensitivity for UTUC: <50%

Contrast Considerations

Iodinated contrast agents:

• • Modern agents: Non-ionic, low-osmolar (safer profile)
• • Volume: Typically 100-150 mL depending on body weight and protocol

Contrast-induced acute kidney injury (CI-AKI):

• • Risk factors: Pre-existing renal impairment, diabetes, dehydration, multiple contrast doses
• • Prevention: Hydration, avoiding nephrotoxic drugs, dose limitation
• • Risk is very low with normal kidney function

eGFR thresholds (typical guidelines):

• • eGFR >60: Proceed with standard precautions
• • eGFR 30-60: Proceed with caution, ensure hydration
• • eGFR <30: Alternative imaging preferred (MRI urography or ultrasound)

Allergic reactions:

• • Mild (1-3%): Urticaria, pruritus, nausea—usually self-limiting
• • Moderate (<1%): Bronchospasm, facial oedema—treatable
• • Severe (<0.04%): Anaphylaxis—very rare but potentially life-threatening

Pre-medication for previous reactions:

• • Corticosteroids (e.g., prednisone 50mg at 13, 7, and 1 hour before)
• • Antihistamine (e.g., diphenhydramine 50mg 1 hour before)
• • Consider alternative imaging if previous severe reaction

MRI Urography

When CT is contraindicated:

• • Severe contrast allergy (though pre-medication may allow CT)
• • Significant renal impairment (eGFR <30)
• • Pregnancy (avoiding radiation)

MRI urography advantages:

• • No ionising radiation
• • Gadolinium contrast has different safety profile
• • Excellent soft tissue detail
• • Good for characterising renal masses

MRI urography limitations:

• • Less sensitive for small stones
• • Longer acquisition time
• • More expensive and less available
• • Claustrophobia issues for some patients
• • Gadolinium concerns in severe renal impairment (nephrogenic systemic fibrosis—very rare with modern agents)

The Importance of Combined Imaging and Cystoscopy

A critical point for patient understanding:

Imaging alone is insufficient for complete bladder assessment.

Even the best CT urography can miss:

• • Flat urothelial lesions (carcinoma in situ)
• • Small papillary tumours
• • Subtle mucosal changes

This is why cystoscopy remains essential. The combination of:

• • CT urography (kidneys, ureters, structural assessment)
• • Cystoscopy (direct bladder mucosal visualisation)

...provides comprehensive evaluation of the entire urinary tract.

</details>

Imaging: Key Points

[SUMMARY CARD]

✓ Ultrasound is a good initial test—safe, no radiation, readily available

✓ CT urogram is the gold standard for detailed assessment, especially for detecting small tumours and upper tract problems

✓ CT urogram requires a kidney function check and allergy screening beforehand

✓ The choice depends on your risk factors and individual circumstances

✓ Important: Even with normal imaging, cystoscopy is usually still needed to directly examine the bladder lining

SECTION 6: Focus on Cystoscopy

Layperson Tier

Looking Directly Inside Your Bladder

Cystoscopy is a procedure where I use a thin telescope with a light and camera to look directly at the lining of your bladder and urethra. This direct view is the definitive way to check for tumours, inflammation, stones, or other abnormalities that might be causing bleeding.

I understand that the idea of this procedure can sound daunting. Let me explain exactly what happens, so you know what to expect.

Flexible Cystoscopy: The Standard Outpatient Check

[ICON: Flexible Scope]

This is the most common type, performed in my clinic whilst you're awake. The telescope is thin (about the thickness of a pencil) and flexible, so it can bend and navigate gently through your anatomy.

What happens:

1. 1. You stay awake in a dedicated clinic room
2. 1. Local anaesthetic gel is inserted into your urethra several minutes before we start—this numbs the area and makes passage much more comfortable
3. 1. Positioning: You lie on an examination couch in a reclined position
4. 1. The procedure: I gently pass the flexible cystoscope through your urethra into your bladder. You'll feel some pressure and perhaps an odd sensation, but most patients find it much less uncomfortable than they expected
5. 1. Filling the bladder: As the scope enters your bladder, I fill it with sterile water to open up the walls and see everything clearly
6. 1. The examination: I systematically examine every part of the bladder lining, rotating and angling the camera to check all areas
7. 1. Duration: The actual examination takes only 5-10 minutes
8. 1. Watching along: You can watch the images on a screen if you wish—many patients find this fascinating and reassuring

What Most Patients Tell Me Afterwards

[TESTIMONIAL STYLE QUOTES]

"It was nowhere near as bad as I'd built it up to be."

"A bit uncomfortable, but over quickly."

"I was dreading it, but the doctor explained everything and I could see what was happening on the screen—that actually helped."

After Your Flexible Cystoscopy

[WHAT TO EXPECT CARD]

Normal experiences:

• • Mild stinging or burning when you urinate for the first few times—this usually settles within 6-12 hours
• • Needing to urinate more frequently for a short period
• • Light pink-tinged urine for 24-48 hours (especially if any samples were taken)

You can usually:

• • Drive yourself home
• • Resume normal activities the same day
• • Return to work the next day (or even the same day)

Rigid Cystoscopy: When We Need to Take Samples

[ICON: Operating Theatre]

If flexible cystoscopy or imaging shows something suspicious, I may recommend a rigid cystoscopy. This uses a straight, non-flexible telescope and is performed in an operating theatre under general anaesthetic (asleep) or spinal anaesthetic (numb from the waist down).

Why it's done:

• • To take tissue samples (biopsies) for definitive diagnosis
• • To completely remove a visible tumour (called TURBT—transurethral resection of bladder tumour)
• • For better instrumentation and wider access

What this achieves: When I remove tumour tissue, it serves two purposes:

1. 1. Diagnosis: The pathologist examines the tissue to determine exactly what type of abnormality it is and how deeply it extends
2. 1. Treatment: For many non-muscle-invasive bladder cancers, removing the tumour is also the primary treatment

Recovery:

• • Usually a day-case procedure (home the same day)
• • A temporary catheter may be placed for 12-48 hours
• • Some bladder discomfort, frequency, and blood-tinged urine for a few days afterwards
• • I'll give you clear written instructions and emergency contact information

Enhanced Cystoscopy: Seeing More Clearly

[ICON: Special Light/Enhanced Vision]

In certain situations, I use specialised techniques alongside standard white-light cystoscopy to detect very subtle lesions:

Blue light cystoscopy (Photodynamic Diagnosis): A special solution is put into your bladder beforehand. Abnormal cells absorb this solution and glow bright pink under blue light, making them stand out vividly—even if they'd be hard to see under normal light.

Narrow band imaging (NBI): Uses filtered light to enhance the appearance of blood vessels. Abnormal tumour blood vessels appear more prominent, helping to highlight suspicious areas.

When I use these:

• • For high-grade bladder cancer
• • When urine tests suggest cancer but the bladder looks normal
• • During surveillance for patients with previous bladder cancer

<details> <summary><strong>Deep Dive: Cystoscopy Techniques and Equipment</strong></summary>

Flexible Cystoscopy: Technical Aspects

Equipment

The flexible cystoscope:

• • Outer diameter: Typically 15-17 French (5-5.7mm)
• • Working length: 40-45 cm
• • Deflection: 180-210° up/down tip deflection
• • Working channel: 2.2-2.6 French for instrument passage
• • Video vs fibreoptic: Modern scopes use chip-on-tip video technology for superior image quality

Irrigation:

• • Sterile saline or water
• • Gravity-fed from elevated bag
• • Volume: Typically 200-400mL to adequately distend bladder

Anaesthesia Protocol

Lignocaine gel instillation:

• • Typically 2% lignocaine gel (Instillagel® or equivalent)
• • Volume: 6-11mL for women, 11-20mL for men
• • Dwell time: 5-10 minutes for optimal effect
• • Contains antiseptic (chlorhexidine) in some preparations

Additional considerations:

• • Anxiolysis: Verbal reassurance, distraction techniques, music
• • Some centres offer nitrous oxide (Entonox) for anxious patients
• • Rarely, oral anxiolytics pre-procedure

Examination Technique

Systematic bladder inspection: I follow a systematic approach to ensure complete visualisation:

1. 1. Urethral examination during insertion
2. 1. Trigone and ureteric orifices: Check for abnormalities, observe efflux
3. 1. Bladder neck and posterior wall
4. 1. Dome (often requires retroflexion—bending the scope back on itself)
5. 1. Lateral walls (left and right)
6. 1. Anterior wall
7. 1. Air bubble: Follow it to confirm dome visualisation

Documentation:

• • Video recording (with consent) for reference
• • Diagram annotation of any abnormalities
• • Photography of suspicious lesions

Limitations of Flexible Cystoscopy

What it can miss:

• • Very small flat lesions (CIS)
• • Lesions hidden by trabeculae in severely trabeculated bladders
• • Lesions within diverticula (depending on diverticular neck)
• • Anterior bladder lesions (can be technically challenging)

Biopsy limitations:

• • Cold cup biopsies possible but limited in size
• • Cannot perform complete resection of significant lesions
• • Haemostasis more limited than rigid cystoscopy

Rigid Cystoscopy and TURBT

Equipment

Rigid cystoscopes:

• • Resectoscope: For TURBT, typically 24-28 French outer sheath
• • Examining cystoscope: For examination and biopsy, typically 17-21 French
• • Optical systems: 0°, 30°, 70°, 120° lenses for different viewing angles

Resection equipment:

• • Monopolar or bipolar resection loops
• • Coagulation current for haemostasis
• • Continuous-flow irrigation system
• • Video tower with recording capability

TURBT Technique (Diagnostic Context)

For haematuria investigation, TURBT serves primarily a diagnostic role:

Goals:

1. 1. Complete visible tumour removal
2. 1. Deep resection to include muscle layer (for staging)
3. 1. Systematic sampling of any other suspicious areas
4. 1. Haemostasis

Tissue handling:

• • Separate specimens: Tumour, base of tumour (including muscle), any other biopsied areas
• • Specimen orientation where possible
• • Avoids cautery damage to tissue edges

What the pathologist reports:

• • Histological type (usually urothelial carcinoma)
• • Grade (low-grade vs high-grade)
• • Stage: Presence or absence of muscularis propria (detrusor muscle) invasion
• • Other features: CIS, lymphovascular invasion, variant histology

Enhanced Cystoscopy: Technical Details

Photodynamic Diagnosis (PDD) / Blue Light Cystoscopy

Mechanism: Hexaminolevulinate (HAL, Hexvix®) is instilled into the bladder 1-3 hours before cystoscopy. HAL is taken up preferentially by rapidly proliferating cells (tumour cells) and converted to protoporphyrin IX (PpIX), a fluorescent compound.

Under blue-violet light (380-450nm), PpIX fluoresces bright pink/red, making abnormal areas stand out against the blue background of normal tissue.

Evidence:

• • Meta-analyses show 20-25% improvement in CIS detection
• • 10-20% improvement in Ta tumour detection
• • Associated with reduced recurrence rates when used for TURBT

Limitations:

• • False positives: Recent BCG therapy, inflammation, recent TURBT site
• • False negatives: Heavily cauterised areas
• • Cost and logistical considerations (instillation timing)

Narrow Band Imaging (NBI)

Mechanism: NBI uses optical filters to narrow the bandwidth of light to two specific wavelengths:

• • Blue light (415nm): Absorbed by haemoglobin in superficial capillaries
• • Green light (540nm): Absorbed by haemoglobin in deeper submucosal vessels

This enhances contrast between vascular structures and mucosa, making abnormal tumour vasculature more visible.

Evidence:

• • Improved detection of non-muscle-invasive bladder cancer
• • Particularly useful for detecting flat lesions and small papillary tumours
• • No additional preparation required (unlike PDD)

Availability:

• • Integrated into modern cystoscope systems
• • Can be switched on/off during examination
• • Available for both flexible and rigid cystoscopy

Complications of Cystoscopy

Flexible Cystoscopy Complications

Common (>1%):

• • Dysuria, frequency (24-48 hours)
• • Haematuria (usually mild)
• • UTI (2-5%, reduced with antibiotic prophylaxis in high-risk patients)

Uncommon (<1%):

• • Significant haematuria requiring intervention
• • Urinary retention
• • Urethral trauma or false passage

Rare (<0.1%):

• • Sepsis (if underlying infection)
• • Bladder perforation (extremely rare with flexible scope)

Rigid Cystoscopy/TURBT Complications

Common:

• • Dysuria, frequency
• • Haematuria (may be significant, usually settles within days)
• • UTI

Uncommon:

• • Bladder perforation (intra-peritoneal or extra-peritoneal)
• • Significant bleeding requiring transfusion
• • Urethral stricture (delayed complication)
• • Incomplete resection requiring repeat procedure

Specific to TURBT:

• • TUR syndrome: Hyponatraemia from absorption of hypotonic irrigation fluid (mainly with monopolar resection using glycine; rare with bipolar resection using saline)
• • Obturator nerve stimulation: Leg kick during resection of lateral wall lesions (can cause perforation)

Post-Cystoscopy Care

Standard advice:

• • Increase fluid intake for 24-48 hours
• • Expect some discomfort and blood-tinged urine initially
• • Contact if: Fever, inability to pass urine, significant bleeding, severe pain

When to worry:

• • High fever (>38.5°C)
• • Inability to pass urine
• • Heavy bleeding with clots
• • Severe abdominal pain

</details>

Cystoscopy: Key Points

[SUMMARY CARD]

✓ Flexible cystoscopy is the standard outpatient test—awake, with local anaesthetic, generally well-tolerated

✓ Most patients find it much less uncomfortable than they expected

✓ Rigid cystoscopy (under anaesthetic) is needed if we find something that requires biopsy or removal

✓ Enhanced techniques (blue light, NBI) can detect very subtle lesions

✓ Cystoscopy is essential even when imaging is clear—it's the gold standard for bladder assessment

SECTION 7: When to Seek Urgent Medical Attention

Layperson Tier

Recognising Red Flags

Whilst all haematuria needs investigation, certain situations require immediate medical attention. It's important you know when to act quickly.

🚨 Seek Urgent Help If You Experience:

[ALERT CARDS - Visual Red Flags]

Symptom

Why It's Urgent

Blood clots in your urine

Passing clots often means more significant bleeding. Large clots can block your bladder outlet.

Blood in urine with high fever, shaking, severe back pain

This could indicate a kidney infection (pyelonephritis) requiring urgent antibiotics.

Complete inability to urinate

If you cannot pass urine at all, especially with haematuria, this is a medical emergency. Blood clots may be blocking the bladder outlet.

Blood after significant injury

If you've had trauma to your back, abdomen, or pelvis and then notice blood in your urine, you need urgent assessment for internal injury.

Feeling very unwell with haematuria

Dizziness, fainting, extreme tiredness, looking very pale—these could indicate significant blood loss.

What To Do

[ACTION FLOWCHART]

For visible blood WITHOUT severe symptoms: → Contact your GP surgery urgently (same day if possible) → Visible haematuria is typically managed via the 2-week suspected cancer pathway

For the red flag symptoms above (retention, severe pain + fever, feeling very unwell, post-trauma): → Go directly to your nearest A&E department → Or call 999 if you cannot get there safely

If you're unsure during working hours: → Call NHS 111 for advice → Or contact my practice team directly if you're an existing patient

Why Acting Quickly Matters

[EXPLANATION BOX]

These red flag symptoms indicate conditions needing swift intervention:

• • Clot retention: Can cause severe pain and bladder damage if not relieved quickly
• • Kidney infection: Can rapidly progress to sepsis (a life-threatening systemic infection) without prompt antibiotics
• • Traumatic injury: Urgent imaging and potential intervention are needed to prevent complications

Please don't delay or "wait and see" if you experience these symptoms. Prompt assessment ensures your safety.

SECTION 8: What Happens After Diagnosis

Layperson Tier

From Answers to Your Personalised Plan

Once we've completed all the necessary tests—your consultation, urine and blood tests, imaging, and cystoscopy—we'll have the crucial answer: the underlying cause of your haematuria.

This clear diagnosis allows us to move forward together with the right treatment plan for you.

Understanding Your Results

[ICON: Results Discussion]

I'll sit down with you to explain the findings in detail. We'll establish exactly what's causing the bleeding and what that means for your health.

Important to understand: We're not treating "haematuria" itself (which is a symptom, not a disease). We're treating the specific underlying condition we've identified.

Examples of How Diagnosis Leads to Treatment

[CONDITION → TREATMENT CARDS]

If We Find...

Your Options May Include...

Urinary tract infection

Antibiotics based on culture results. Symptoms usually resolve within days.

Kidney or bladder stones

Watchful waiting, medication to help pass small stones, or procedures to break up/remove larger ones.

Enlarged prostate (BPH)

Lifestyle changes, medications, or surgical procedures depending on severity.

Bladder cancer

Further treatment depends on the type and stage—ranging from bladder treatments to surgery. Detailed on dedicated bladder cancer pages.

Kidney tumour

Usually surgical removal—either the tumour alone or the entire kidney depending on size.

Kidney disease (glomerular)

Referral to a kidney specialist (nephrologist) for specialised management.

No specific cause found

Reassurance that serious problems have been excluded, plus a monitoring plan with follow-up tests.

When No Cause Is Found

[REASSURANCE SECTION]

It's relatively common, particularly with microscopic haematuria in lower-risk patients, for all investigations to come back normal. This is called "idiopathic haematuria."

What this means:

• • We've excluded serious problems to the best of our ability
• • The bleeding may be from tiny, clinically insignificant sources
• • Sometimes the cause genuinely remains unknown

What I recommend:

• • A structured follow-up plan with repeat urine tests at intervals (typically 6, 12, and 24 months)
• • If the haematuria completely resolves and stays away, extended follow-up may not be needed
• • If it persists or worsens, we may repeat investigations after an interval
• • You should contact me if you develop visible bleeding, new symptoms, or concerns

Shared Decision-Making: Working Together

[PARTNERSHIP APPROACH]

The transition from diagnosis to treatment involves us working together. This means:

• • I'll explain your diagnosis clearly and ensure you understand what it means
• • We'll discuss all appropriate treatment options
• • I'll explain the benefits, risks, and likely outcomes of each approach
• • You'll have the opportunity to ask questions—as many as you need
• • Together, we'll agree on a plan that fits your circumstances, preferences, and values

Your informed consent and comfort with the plan are paramount. I'm here to guide you with expert advice, but decisions about your care are made with you, not for you.

<details> <summary><strong>Deep Dive: Condition-Specific Management Pathways</strong></summary>

Urinary Tract Infection (UTI)

Diagnosis: Positive urine culture with pathogenic bacteria

Management:

• • Antibiotics guided by culture and sensitivity results
• • Typical duration: 3-7 days depending on infection type
• • Ensure complete symptom resolution
• • Follow-up urine test to confirm clearance (in selected cases)

If recurrent UTIs:

• • Investigation for underlying causes (stones, residual urine, structural abnormalities)
• • Consider long-term prophylactic strategies

Urinary Stones

Management depends on:

• • Stone size and location
• • Symptoms
• • Stone composition (if known)
• • Kidney function

Options:

• • Conservative management: For small stones (<5mm) likely to pass spontaneously
• • Hydration, analgesia, alpha-blockers (medical expulsive therapy)
• • Extracorporeal shockwave lithotripsy (ESWL): Non-invasive fragmentation of stones
• • Ureteroscopy: Endoscopic stone removal or fragmentation
• • Percutaneous nephrolithotomy (PCNL): For large kidney stones (>2cm)

Prevention:

• • Metabolic evaluation for recurrent stone formers
• • Dietary modifications, increased fluid intake
• • Specific medications based on stone type

Benign Prostatic Hyperplasia (BPH)

Management spectrum:

Watchful waiting:

• • For mild symptoms
• • Annual symptom review

Medical therapy:

• • Alpha-blockers (tamsulosin, alfuzosin): Relax prostate smooth muscle
• • 5-alpha reductase inhibitors (finasteride, dutasteride): Shrink prostate over time
• • Combination therapy for larger prostates

Minimally invasive treatments:

• • UroLift (prostatic urethral lift)
• • Rezūm (water vapour thermal therapy)

Surgical treatments:

• • TURP (transurethral resection of prostate)
• • Holmium laser enucleation (HoLEP)
• • Aquablation
• • Simple prostatectomy (for very large glands)

Bladder Cancer

Staging determines management:

Non-muscle-invasive bladder cancer (NMIBC):

• • Stage Ta, T1, CIS
• • Primary treatment: TURBT (complete resection)
• • Risk stratification: Low, intermediate, high
• • Adjuvant intravesical therapy: Single-dose chemotherapy (all), BCG or further chemotherapy (intermediate/high risk)
• • Surveillance: Regular cystoscopy (frequency determined by risk)

Muscle-invasive bladder cancer (MIBC):

• • Stage T2 or higher
• • Staging CT chest/abdomen/pelvis
• • MDT discussion
• • Radical cystectomy (bladder removal) with urinary diversion
• • Or bladder-sparing approach: Maximal TURBT + radiotherapy + chemotherapy
• • Neoadjuvant chemotherapy consideration

Metastatic disease:

• • Systemic chemotherapy
• • Immunotherapy (checkpoint inhibitors)
• • Palliative care and symptom management

Detailed management information available on dedicated bladder cancer treatment pages.

Renal Cell Carcinoma (Kidney Cancer)

Workup:

• • Staging CT chest/abdomen/pelvis
• • MRI if needed for local staging

Management options:

Small renal masses (<4cm):

• • Active surveillance (especially in elderly/comorbid patients)
• • Partial nephrectomy (nephron-sparing surgery)
• • Ablative therapies (radiofrequency or cryoablation)

Larger tumours:

• • Radical nephrectomy (laparoscopic or robotic)
• • Partial nephrectomy if technically feasible (to preserve kidney function)

Metastatic disease:

• • Targeted therapies (tyrosine kinase inhibitors)
• • Immunotherapy (checkpoint inhibitors)
• • Cytoreductive nephrectomy in selected cases

Glomerular Disease

Indicators:

• • Dysmorphic red cells on microscopy
• • Red cell casts
• • Significant proteinuria
• • Reduced kidney function

Management:

• • Nephrology referral
• • Consider kidney biopsy for definitive diagnosis
• • Disease-specific treatment (may include immunosuppression)
• • Blood pressure control (ACE inhibitors/ARBs)
• • Regular monitoring of kidney function and proteinuria

Common glomerular causes of haematuria:

• • IgA nephropathy (Berger's disease)
• • Thin basement membrane disease
• • Alport syndrome
• • Post-infectious glomerulonephritis

Idiopathic Haematuria (No Cause Found)

Definition: Persistent or recurrent haematuria with normal comprehensive investigation

Approach:

Reassurance:

• • Serious pathology has been excluded
• • Many cases remain unexplained despite thorough investigation
• • Prognosis is generally excellent

Monitoring protocol:

• • Repeat urinalysis at 6, 12, and 24 months
• • Blood pressure monitoring
• • Kidney function monitoring
• • Repeat imaging/cystoscopy only if changes develop

When to re-investigate:

• • Development of visible haematuria
• • Increasing microscopic haematuria
• • New symptoms (pain, weight loss, etc.)
• • New risk factors
• • Declining kidney function

Potential benign causes:

• • Thin basement membrane nephropathy ("benign familial haematuria")
• • Nutcracker syndrome (rare)
• • Exercise-induced haematuria
• • Minor vascular abnormalities

</details>

Finding More Information

[NAVIGATION CARD]

For detailed information about treatment options once a diagnosis is made, please visit the relevant sections of the GGO Med website:

• • Bladder Cancer → /condition/bladder-cancer
• • Kidney Cancer → /condition/kidney-cancer
• • Kidney Stones → /condition/kidney-stones
• • Enlarged Prostate (BPH) → /condition/bph
• • Lower Urinary Tract Symptoms → /symptom/urine-issues

SECTION 9: Frequently Asked Questions

Layperson Tier

[FAQ ACCORDION COMPONENT]

Q: Does blood in urine always mean cancer?

A: No, absolutely not. Whilst cancer is one of the serious causes I must actively rule out, it's certainly not the most common cause overall. Many cases are due to entirely benign conditions—urinary tract infections, kidney stones, or benign prostate enlargement are all more common than cancer.

However, because cancer can present with haematuria—and early detection dramatically improves treatment success—systematic investigation is essential. The diagnostic pathway is designed to identify or rule out cancer efficiently whilst also finding any other underlying cause.

Try not to jump to the worst conclusion, but equally, please don't ignore haematuria.

Q: I only saw blood once, weeks ago, and it hasn't come back. Does it still need checking?

A: Yes, investigation is still recommended. A single episode of visible haematuria can still indicate an underlying problem. Many bladder tumours cause intermittent bleeding—you might see blood once, then nothing for weeks or months, then it recurs.

The fact that bleeding has stopped doesn't mean the underlying cause has resolved. National guidelines recommend investigation even for a single episode of visible haematuria in adults with risk factors.

Q: My urine dipstick was positive for blood, but microscopy was normal. What does this mean?

A: This can be confusing. A positive dipstick without actual red blood cells on microscopy can occur for several reasons:

• • Haemoglobinuria or myoglobinuria: Free haemoglobin from broken-down red cells, or myoglobin from muscle breakdown
• • Very dilute urine: Red cells may have burst before microscopy was done
• • Menstrual contamination in women
• • Laboratory timing issues

The usual approach is to repeat the test with a properly collected sample. If repeatedly positive on dipstick but negative on microscopy, the clinical significance is lower—but I may still investigate if you have risk factors.

Q: Is a flexible cystoscopy painful?

A: The honest answer is that most patients find it much less uncomfortable than they expected.

I use local anaesthetic gel to numb the urethra beforehand, and the flexible nature of the scope allows it to navigate gently. You'll likely feel some odd sensations—pressure, a feeling of needing to urinate, perhaps mild stinging—but most people describe it as uncomfortable or awkward rather than painful.

A very small percentage of patients find it more uncomfortable (typically those with particularly sensitive urethras or previous scarring). I'm always gentle and go at a pace you're comfortable with. The examination takes only 5-10 minutes, and the relief of getting answers usually far outweighs the brief discomfort.

Q: Why might I need both a CT scan AND a cystoscopy?

A: This is a very common question. The simple answer is that these tests assess different things and work together:

CT urogram is excellent for imaging the kidneys, ureters, and detecting stones, kidney tumours, and ureteric tumours. However, it can sometimes miss small, flat bladder lesions.

Cystoscopy provides direct, magnified visualisation of the bladder lining. This is the gold standard for bladder assessment and can detect early cancers that CT doesn't pick up.

Think of it like checking a house: CT is like an aerial photograph showing the overall building, whilst cystoscopy is like walking through every room to check the walls closely. Both perspectives are needed for complete assessment.

Q: What happens if no cause is found for my haematuria?

A: This situation is actually relatively common, particularly in lower-risk patients with microscopic haematuria. If all tests are normal, we call this "idiopathic haematuria."

What I'll do:

• • Reassure you that we've excluded serious problems to the best of our ability
• • Set up a follow-up plan with repeat urine tests at intervals (typically 6, 12, and 24 months)
• • Advise you to contact me if you develop visible blood, new symptoms, or concerns

If the haematuria completely resolves, extended follow-up may not be needed. If it persists or increases, we may repeat some investigations after an interval.

The key point is that even with no cause found now, we've established a baseline and a monitoring plan to catch anything that might develop later.

[QUIZ COMPONENT: "Test Your Understanding"]

Plan for Interactive Quiz:

1. 1. Risk factors question: Which of these is NOT a major risk factor for bladder cancer? (Age over 50 / Smoking / Regular exercise / Occupational chemical exposure)
2. 1. Investigation purpose: The main reason for doing cystoscopy even when CT scan is normal is... (To check kidney function / To directly visualise the bladder lining / To take blood samples / To measure urine flow)
3. 1. When to seek urgent help: Which of these requires A&E attendance? (Pink-tinged urine / Unable to pass urine at all / Mild burning when urinating / Needing to urinate more often)
4. 1. True or False: A single episode of visible blood in urine that doesn't recur doesn't need investigation. (False)
5. 1. Match the test to its purpose: CT urogram → Detailed imaging of kidneys and ureters; Cystoscopy → Direct bladder visualisation; Urine cytology → Looking for abnormal cells

SECTION 10: About Mr Ollandini & Next Steps

Layperson Tier

About Your Consultant

[PROFILE SECTION]

I'm a Consultant Urological Surgeon with specialist expertise in andrology, male sexual health, male infertility, and urological cancer diagnosis. My practice is built on three core principles:

1. 1. Evidence-based clinical excellence – Following the latest guidelines and research
2. 1. Clear patient communication – Medical information should be understandable
3. 1. Compassionate, individualised care – Every patient's situation is unique

I believe that facing potential health concerns like haematuria requires not just expert investigation, but also genuine understanding and support. My commitment is to guide you through the diagnostic process with meticulous attention to detail whilst ensuring you feel informed, heard, and supported at every step.

My Approach to Haematuria Investigation

[APPROACH CARDS]

Principle

What This Means for You

Systematic & Thorough

I follow evidence-based pathways whilst tailoring investigations to your circumstances

Clear Communication

I explain findings and options in plain language, answering all your questions

Efficiency & Urgency

Where indicated, investigations proceed swiftly via NHS fast-track or rapid private routes

Collaborative Decisions

Your preferences guide our shared decisions about investigation and management

Where I Practice

[LOCATION CARDS]

Chelsea and Westminster Hospital Private Care 369 Fulham Road, London SW10 9NH

Nuffield Health Highgate Hospital 17-19 View Road, London N6 4DJ

Virtual Consultations Available nationwide

Taking Action

[CTA SECTION]

Discovering blood in your urine is understandably concerning, but taking action to get an accurate diagnosis is the most important step you can take for your urological health and peace of mind.

The diagnostic pathway is well-established, efficient, and designed to provide answers safely and thoroughly. Whether the cause turns out to be straightforward or more complex, understanding it through proper investigation allows us to move forward together with the right plan.

Don't ignore haematuria—address it with expert help.

Book Your Consultation

[BOOKING WIDGET PLACEHOLDER]

Private Consultations:

• • Can be arranged directly without GP referral
• • Often available within days
• • Comprehensive investigation pathway

NHS Pathway:

• • Requires GP referral
• • Visible haematuria: Typically 2-week suspected cancer pathway
• • Your GP can arrange urgent referral

Contact: [Contact details / Booking link]

Medical Disclaimer

[LEGAL/DISCLAIMER BOX]

This guide provides educational information about haematuria diagnosis based on current UK medical practice and evidence-based guidelines. It does not constitute specific medical advice for your individual condition.

An accurate diagnosis can only be reached after personal consultation with a qualified urologist, detailed review of your medical history, physical examination, and appropriately tailored investigations.

Please do not use this information alone to self-diagnose or make decisions about your health. Always consult your GP or a specialist urologist for any health concerns.

APPENDIX: Required Visual Assets

Photos/Illustrations Needed

Section 3: Risk Factors

• • Icon set for risk factor cards (age, smoking, gender, occupation, radiation, bladder irritation)
• • Risk stratification visual/infographic
• • Scale/spectrum graphic showing low to high risk

Section 4: Diagnostic Pathway

• • Step-by-step pathway infographic
• • Consultation icon
• • Test tube/urine sample icon
• • Blood vial icon
• • Imaging/scanner icon
• • Camera/scope icon
• • Flowchart showing tailored pathways

Section 5: Imaging

• • Ultrasound illustration (non-threatening, educational)
• • CT scanner illustration
• • Sample ultrasound image (educational, anonymised)
• • Sample CT urogram image (educational, anonymised)
• • Results flowchart graphic

Section 6: Cystoscopy

• • Flexible cystoscope illustration
• • Patient positioning illustration (tasteful, educational)
• • Bladder interior view (educational graphic, not disturbing)
• • Operating theatre icon for rigid cystoscopy
• • Blue light cystoscopy comparison image
• • Before/after flexible cystoscopy "what to expect" graphic

Section 7: Red Flags

• • Alert/warning icons
• • Emergency services icon
• • Action flowchart graphic

Section 8: After Diagnosis

• • Results discussion illustration
• • Treatment pathway cards
• • Partnership/collaboration graphic

Section 9: FAQs

• • Question mark icons
• • Quiz component graphics

Section 10: About/CTA

• • Professional headshot of Mr Ollandini
• • Location/clinic photos
• • Map graphics for clinic locations
• • Booking/calendar icon

APPENDIX: Interactive Component Specifications

Card Grids

• • Risk Factor Cards (6 cards) - Section 3
• • Condition → Treatment Cards (7 cards) - Section 8
• • Approach Cards (4 cards) - Section 10
• • Location Cards (3 cards) - Section 10

Expandable Sections (Deep Dives)

• • Section 3: Evidence Behind Risk Stratification (~800 words)
• • Section 4: Clinical Reasoning and Protocols (~1200 words)
• • Section 5: Imaging Modalities in Detail (~1500 words)
• • Section 6: Cystoscopy Techniques and Equipment (~1500 words)
• • Section 8: Condition-Specific Management Pathways (~1200 words)

FAQ Accordion

• • 6 questions with expandable answers
• • Section 9

Quiz Component

• • 5 questions
• • Multiple choice and true/false formats
• • Immediate feedback
• • Section 9

Flowcharts/Diagrams

• • Diagnostic pathway flowchart - Section 4
• • Imaging results pathways - Section 5
• • Urgent action flowchart - Section 7

CTAs (Call to Action)

• • End of Section 3
• • End of Section 5
• • End of Section 6
• • Section 10 (primary booking CTA)

Summary Cards

• • End of Section 3
• • End of Section 4
• • End of Section 5
• • End of Section 6

Document prepared following GGO Med brand guidelines First-person voice | UK English | Plus Jakarta Sans typography Teal #00EEB6 | Clinical Blue #3208F5 | Soft Blue #E3EEFD | Charcoal #4B4B4B