The first step in getting to the bottom of the hematuria problem is to obtain a thorough history. There are many clues to unearth from the patient that can help the urologist find the cause of the blood in the urine.
Certain causes of hematuria are more common at different ages.
In children, glomerulonephritis and urinary tract infections are common causes of hematuria. A child with a dilated kidney, often unsuspected, is also prone to hematuria, especially after what seems to be a minor trauma.
In young adults, gross hematuria is usually the result of infection, either pyelonephritis (infection of the kidney) or cystitis (infection of the bladder). Stones within the kidney and ureter also cause hematuria in this age group.
In adults older than 40 years of age, infections are still the most common cause of hematuria. However, cancers of the kidneys, ureters, and bladder become more common. In men, benign enlargement of the prostate and prostate cancer are common causes of hematuria.
Initial hematuria describes blood at the beginning of the urinary stream. It is usually produced by lesions of the prostate. Blood is produced by a problem within the prostate, accumulates within the lumen of the prostate, and is voided out first, followed by yellow urine from the bladder.
Terminal hematuria describes blood at the end of the urinary stream. It may result from lesions of the prostate or the bladder, such as bladder stones and rarely bladder cancer.
Total hematuria describes bloody urine throughout the entire urinary stream. It is commonly the result of lesions of the kidneys and ureters. Blood from the kidneys and ureters enters the bladder, mixes with the urine already in the bladder, turning it red. Bladder infections and bladder cancer are also common causes of total hematuria.
When the hematuria is associated with pain in the back or the flank, a blocked kidney should be suspected. Blocked kidneys are the result of blood clots, or more commonly, stones. When burning with urination is present with the hematuria, a urinary tract infection should be suspected. Painless total hematuria is a classic presentation for bladder cancer.
Many patients have problems such as heart disease and strokes, and require blood thinners, such as Coumadin, Aspirin, Plavix, and Ticlid. Lesions of the urinary tract will be unmasked at an earlier stage in patients taking these blood thinners. An important point to remember is not to blame the hematuria solely on the blood thinners, as 80% of men with gross hematuria on blood thinners have significant urologic problems.
A history of radiation to the pelvis to treat cancers of the prostate, bladder, uterus, cervix, ovary, and bowels is important because radiation may cause hematuria shortly afterwards or even years later. Hematuria occurs in 3 to 12% of patients years after receiving the radiation.