JAMA PATIENT PAGE | Urological Disorders
Blood in the Urine (Hematuria)
A discoloration of urine may be due to a medication,
something a person ate, or a variety of medical causes.
Blood in the urine (hematuria) commonly causes pink or red dis-
coloration and should prompt medical evaluation.
What Is Hematuria?
Hematuria may be visible with the naked eye (gross hematuria) or
visible only under a microscope (microscopic hematuria). The urine
may look normal in patients who have have microscopic hematuria.
Risk of Hematuria
Hematuria is common, seen in 2% to 30% of the adult population.
Older patients and smokers have higher rates of hematuria. Smok-
ers are also at an increased risk of genitourinary cancer.
Causes of Hematuria
Hematuriacanbecausedbyanumberofdifferentthings,someofwhich
arebladderorkidneystones;kidneydisease;urinarytractinfection,cys-
titis (bladder infection), or pyelonephritis (kidney infection); cancers
oftheurinarytract(kidney,bladder,prostate);trauma,injury,orurinary
tract instrumentation; rigorous exercise; benign prostatic hyperpla-
sia (enlarged prostate); and blood thinners (aspirin, warfarin, etc).
Hematuria can be confused with other urine discoloration
caused by something other than blood in the urinary tract, such as
foods like beets, bleeding from menstruation, blood from the gas-
trointestinal system, or medications.
Medical Evaluation of Hematuria
If you see blood in your urine, you should tell your primary care doc-
tor. Otherwise, hematuria is usually detected during routine evaluation
and without any other signs or symptoms. Sometimes, this happens
withadipstickurinetest,whichcanhavehighfalse-positiveresultrates.
Therefore, all cases of hematuria must be confirmed in a laboratory by
seeing 3 or more red blood cells in a sample under a microscope.
Doctors generally use practice guidelines as an aid to evalua-
tion. At this time, national guidelines recommend a complete evalu-
ation in all patients aged 35 years or older who have hematuria with-
out an obvious benign cause. Patients are typically referred to a
urologist (a surgeon of the urinary tract) and sometimes a nephrolo-
gist (a kidney specialist) for this evaluation.
A timely and complete evaluation of hematuria is essential be-
cause a delay in diagnosis can be serious. Your treatment team should
Authors: Richard S. Matulewicz, MD, MS; Joshua J. Meeks, MD, PhD
Conflict of Interest Disclosures: The authors have completed and submitted the
ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Sources: Davis R, Jones JS, Barocas DA, et al. Diagnosis, evaluation and follow-up of
asymptomatic microhematuria (AMH) in adults: AUA guideline. J Urol. 2012;188(6)
(suppl):2473-2481.
Nielsen M, Qaseem A; High-Value Care Task Force of the American College of
Physicians. Hematuria as a marker of occult urinary tract cancer: advice for high-value
care from the American College of Physicians. Ann Intern Med. 2016;164(7):488-497.
1508 JAMA October 11, 2016 Volume 316, Number 14 (Reprinted)
Copyright 2016 American Medical Association. All rights reserved.
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Urinary tract anatomy
Microscopic
Kidney hematuria
Red blood cell
Ureter
URINE
Bladder
Prostate
Urethra (men only)
coordinate an evaluation of the entire urinary system. This will likely
include urinary tract imaging and a cystoscopy to help determine the
cause of the hematuria.
Imagingoftheurinarytractusuallyconsistsofacomputedtomog-
raphy (x-ray) scan or an ultrasound. The purpose of imaging is to see
if there are any stones, kidney abnormalities, or tumors in the urinary
tract. A cystoscopy is an examination of the bladder with a small
telescope-likedevicethroughtheurethra(thetubethroughwhichurine
passes out of the body). This is typically performed in an office setting
usingalocalanesthetic.Thegoalofthecystoscopyistolookforanysmall
orflattumorsontheliningofthebladderthatcanbemissedbyimaging.
Even a thorough evaluation may not determine the cause of he-
maturia. Evaluations that find no causes are both common and en-
couraging. However, hematuria persists in some patients. Contin-
ued follow-up with a primary care doctor or specialist may be
recommended for up to 3 years. You should tell your doctor about
any changes in the frequency or severity of hematuria.
FOR MORE INFORMATION
• National Institute of Diabetes and Digestive and Kidney Diseases
www.niddk.nih.gov/health-information/health-topics/urologic
-disease/hematuria-blood-in-the-urine/Pages/facts.aspx
• Urology Care Foundation
www.urologyhealth.org/urologic-conditions/hematuria
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