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Hematuria is the presence of blood in the urine;

greater than
three red blood cells per high-power
microscopic field
(HPF) is significant.
Patients with gross hematuria are usually frightened
by the sudden onset of blood in the urine and
frequently present to the emergency department for
evaluation, fearing that they may be bleeding
Hematuria of any degree should never be ignored and,
in adults, should be regarded as a symptom of
urologic malignancy until proved otherwise.
In evaluating hematuria, several questions should
always be asked, and the answers will enable the
urologist to target the subsequent diagnostic
evaluation efficiently:
Is the hematuria gross or microscopic?
At what time during urination does the hematuria
occur (begin-ning or end of stream or during
entire stream)?
Is the hematuria associated with pain?
Is the patient passing clots?
If the patient is passing clots, do the clots have a
specific shape?

Gross versus Microscopic Hematuria. The significance

of gross versus microscopic hematuria is simply that
the chances of identifying significant pathology
increase with the degree of hematuria.
Thus patients with gross hematuria usually have
identifiable underlying pathology, whereas it is quite
common for patients with minimal degrees of
microscopic hematuria to Have a Negative urologic
Timing of Hematuria. The timing of hematuria during
urination frequently indicates the site of origin.
Initial hematuria usually arises from the
urethra; it occurs least commonly and is usually
secondary to inflammation.

Total hematuria is most common and indicates

that the bleeding is most likely coming from the
bladder or upper urinary tracts.

Terminal hematuria occurs at the end of micturition

and is usually secondary to inflammation in the
area of the bladder neck or prostatic urethra. It
occurs at the end of micturition as the bladder
neck contracts, squeezing out the last amount of

Association with Pain. Hematuria, although frightening,

is usually not painful unless it is associated with
inflammation or obstruction.
Thus patients with cystitis and secondary hematuria
may experience painful urinary irritative symptoms,
but the pain is usually not worsened with passage of
More commonly,pain in association with
hematuria usually results from upper urinary
tract hematuria with obstruction of the ureters
with clots. Passage of these clots may be associated
with severe, colicky flank pain similar to that produced
by a ureteral calculus, and this helps identify the
source of the hematuria.
Presence of Clots. The presence of clots usually
indicates a more significant degree of hematuria, and,
accordingly, the probability of identifying significant
urologic pathology increases.
Shape of Clots. Usually, if the patient is passing clots,
they are amorphous and of bladder or prostatic
urethral origin. However, the presence of
vermiform (wormlike) clots, particularly if
associated with flank pain, identifies the
hematuria as coming from the upper urinary
tract with formation of vermiform clots within the
ureter. It cannot be emphasized strongly enough that
hematuria, particularly in the adult, should be

regarded as a symptom of malignancy until

proved otherwise and demands immediate
urologic examination.
In a patient who presents with gross hematuria,
cystoscopy should be performed as soon as possible,
because frequently the source of bleeding can be
readily identified.
Cystoscopy will determine whether the hematuria is
coming from the urethra, bladder, or upper urinary
tract. In patients with gross hematuria secondary to
an upper tract source, it is easy to see the jet of red
urine pulsing from the involved ureteral orifice.
Although inflammatory conditions may result in
hematuria, all patients with hematuria, except
perhaps young women with acute bacterial
hemorrhagic cystitis, should undergo urologic
Older women and men who present with hematuria
and irritative voiding symptoms may have cystitis
secondary to infection arising in a necrotic bladder
tumor or, more commonly, flat carcinoma in situ of the
The most common cause of gross hematuria in a
patient older than age 50 years is bladder