Haematuria
Haematuria is the presence of red blood cells in the urine, which may be visible (gross) or detectable only on microscopy (microscopic), indicating potential urological, nephrological, or systemic disease.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | UTI / Cystitis | Dysuria, frequency, urgency, +ve urine culture | 「痾尿有冇赤痛、好密、好急？」 |
| Urinary tract stones (nephrolithiasis) | Colicky loin-to-groin pain, haematuria | 「有冇突然嚟嘅腰痛、痛到去下腹/陰部？」 | |
| BPH (in older males) | LUTS (hesitancy, poor stream, nocturia), enlarged prostate on DRE | 「有冇夜晚起身痾尿、等好耐先出、射唔遠？」(DRE: smooth enlarged prostate) | |
| Serious Not To Miss | Bladder cancer | Painless gross haematuria + smoking + older age + weight loss [2][5] | 「小便有血但唔痛？有冇食煙？有冇瘦咗？」 |
| Renal cell carcinoma | Classic triad: haematuria, flank pain, palpable mass (only 10% have all 3) | 「有冇摸到腰邊有嘢脹？」(Ballotable flank mass) | |
| Rapidly progressive GN (e.g. anti-GBM / Goodpasture) | Haematuria + AKI + haemoptysis = pulmonary-renal syndrome [7] | 「有冇咳血？」 | |
| Prostate cancer | Hard irregular prostate on DRE, raised PSA | DRE: hard, nodular, irregular prostate | |
| Pitfalls | IgA nephropathy | Synpharyngitic haematuria, episodic cola-coloured urine [3][4] | 「喉嚨痛嗰時同時出現血尿？」 |
| Renal TB | Sterile pyuria + haematuria + CXR abnormal | 「有冇長期發燒、夜晚出汗、咳？有冇接觸過肺結核病人？」 | |
| Endometriosis (cyclical haematuria in women) | Haematuria coinciding with menses | 「血尿有冇同月經一齊嚟？」 | |
| Masquerades | Drugs (anticoagulants, NSAIDs) | Drug history reveals warfarin/DOAC/NSAID use | 「食緊咩藥？有冇薄血丸、止痛藥？」 |
| Rhabdomyolysis (myoglobinuria) | Dipstick +ve for blood but microscopy -ve for RBC; ↑↑CK [8] | 「最近有冇做劇烈運動、跌倒壓傷？」 | |
| Food/drug discolouration (pseudo-haematuria) | Beetroot, rifampicin, phenazopyridine | 「最近有冇食紅菜頭？有冇食結核藥？」 | |
| Trying to Tell Me Something? | Health anxiety / cancer phobia | Fear triggered by relative/friend diagnosed with cancer | 「有冇嘢令你特別驚？屋企人有冇最近先確診癌症？」 |
| Domestic violence / trauma | Haematuria from blunt trauma, reluctant to disclose | 「有冇跌親或者撞親腰？」(sensitive questioning) |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, introduce self, set agenda | 「你好呀！我姓X，係今日幫你睇症嘅醫學生。今日想了解下你嘅情況，傾大概六分鐘，有咩唔舒服可以慢慢講。」 | Builds rapport; scores interpersonal marks for greeting + signposting |
| 0:30–1:30 | Chief complaint + HPI: onset, duration, character of haematuria (gross vs microscopic), timing (initial/terminal/total stream), colour, clots, pain, frequency, associated LUTS | 「你幾時開始發現有血尿㗎？係成篤都紅色定係得頭/尾先有？有冇血塊？痛唔痛？」 | Defines the haematuria pattern – key discriminator between glomerular vs urological cause [1][2] |
| 1:30–2:30 | Red flags & systems review: weight loss, bone pain, fever, night sweats, loin pain, dysuria, URTI/sore throat preceding episode, joint pain, rash, recent trauma, anticoagulant use | 「有冇瘦咗？有冇骨痛、發燒、夜晚出汗？有冇試過喉嚨痛之後先出現血尿？」 | Screens malignancy, GN (IgA nephropathy synpharyngitic pattern), infection, systemic vasculitis [3][4] |
| 2:30–3:30 | PMH, drug Hx, allergy, FHx, social Hx (smoking, occupation – dye/chemical exposure, sexual Hx if relevant) | 「以前有冇咩大病？食緊咩藥？有冇食薄血丸？有冇煙癮？做邊行㗎？屋企人有冇腎病？」 | Smoking + occupational exposure → bladder Ca risk; drugs (NSAIDs, anticoagulants); FHx → Alport/TBMD/PKD [2][5] |
| 3:30–4:30 | ICE – Ideas, Concerns, Expectations | 「你自己覺得咩原因呢？（Ideas）你最擔心啲咩？（Concerns）你今日嚟睇醫生，最希望我哋幫到你啲咩？（Expectations）」 | Directly examined in CRF Q3; uncovers hidden agenda |
| 4:30–5:15 | Uncover hidden agenda / "Why today?" – explore psychosocial triggers | 「其實你留意到血尿有一排㗎喇，點解揀今日先嚟睇呢？有冇嘢令你特別擔心？」 | The RFC may differ from the symptom (e.g. fear of cancer, relative just diagnosed with kidney disease) |
| 5:15–5:45 | Summarise back, check understanding | 「等我總結返：你發現咗X個禮拜嘅血尿，冇痛，冇……你最擔心係……我講得啱唔啱？」 | Scores marks for summarising + patient-centred communication |
| 5:45–6:00 | Closing: safety-net + plan | 「我會同上級醫生傾，安排驗小便同照超聲波。如果突然痾好多血或者痾唔到小便，要即刻去急症室。」 | Safe close; demonstrates safety-netting |
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Onset/Duration | When did you first notice blood in urine? | 「你幾時第一次發現小便有血？」 | Acute vs chronic; new-onset painless → malignancy | Bladder/renal Ca if chronic painless |
| Colour/Character | What colour – bright red, dark/smoky, cola-coloured? Any clots? | 「係鮮紅色、深啡色、定可樂色？有冇血塊？」 | Clots suggest lower urinary tract source; cola/smoky → glomerular [3][4] | Glomerular (smoky, no clots) vs urological (bright red, clots) |
| Stream timing | Blood at start, end, or throughout? | 「係開頭有血、尾段有、定成篤都有？」 | Initial = urethral; terminal = bladder neck/prostate; total = bladder/upper tract [1] | Terminal → bladder Ca, BPH |
| Pain | Any loin/flank pain or suprapubic pain? | 「有冇腰痛、肚痛？」 | Painful → stones, UTI, IgA nephropathy; painless → malignancy [2][5] | Renal colic → stones; painless → Ca |
| LUTS | Frequency, urgency, poor stream, hesitancy? | 「有冇小便密咗、急、射唔遠、要等？」 | BPH, bladder Ca, UTI | BPH, prostate Ca |
| Dysuria | Pain/burning on urination? | 「痾尿痛唔痛？有冇赤痛？」 | UTI, urethritis | UTI, STI |
| Red flags – weight loss | Unintended weight loss? | 「有冇唔知點解瘦咗？」 | Weight loss + painless haematuria = malignancy until proven otherwise [2] | Renal cell Ca, bladder Ca, urothelial Ca |
| Red flags – fever | Any fever or rigors? | 「有冇發燒、發冷？」 | Pyelonephritis, renal abscess | Complicated UTI |
| Preceding URTI | Sore throat before blood in urine? | 「出血尿之前有冇喉嚨痛、傷風？」 | IgA nephropathy: synpharyngitic haematuria (concurrent with URTI) [3][4] | IgA nephropathy |
| Skin/Joints | Rash, joint pain, mouth ulcers, hair loss? | 「有冇出紅疹、關節痛、口瘡、甩頭髮？」 | Autoimmune/vasculitis (SLE, IgA vasculitis) [6] | Lupus nephritis, Henoch-Schönlein purpura |
| Drug Hx | NSAIDs, anticoagulants, antibiotics? | 「有冇食止痛藥、薄血丸？」 | NSAIDs → interstitial nephritis / GI bleed; anticoagulants unmask underlying pathology | Drug-induced nephritis; anticoagulant still needs workup |
| Smoking | Do you smoke? How much? | 「有冇食煙？食咗幾耐？」 | Smoking is the strongest risk factor for bladder cancer [2][5] | Transitional cell Ca of bladder |
| Occupation | Exposure to dyes, rubber, chemicals? | 「返咩工？有冇接觸染料、化學品？」 | Aromatic amine exposure → bladder Ca | Occupational bladder Ca |
| FHx | Kidney disease, deafness in family? | 「屋企人有冇腎病、聽覺差？」 | Alport syndrome: FHx of renal failure + deafness in male relatives; TBMD: FHx of benign haematuria [4] | Alport, ADPKD, TBMD |
| Sexual Hx | Urethral discharge? Unprotected sex? | 「有冇尿道有嘢流出嚟？有冇唔安全嘅性行為？」 | STI-related urethritis; schistosomiasis if travel Hx | Urethritis, schistosomiasis |
| Travel Hx | Recent travel to Africa/Middle East? | 「最近有冇去過非洲、中東？」 | Schistosomiasis endemic areas | Schistosomiasis |
| Functional impact | How is this affecting your daily life/work/mood? | 「血尿對你日常生活、返工、心情有冇影響？」 | Biopsychosocial assessment for CRF | Anxiety, time off work |
Case Report Form Answer Builder
Write: "Haematuria for [duration]" — include:
- Onset, duration, intermittent vs persistent
- Gross vs microscopic; colour (bright red / smoky / cola)
- Timing in stream (initial / terminal / total)
- Presence of clots (clots → lower tract; no clots, smoky → glomerular) [1][4]
- Associated: pain (loin/suprapubic/dysuria), LUTS, systemic symptoms (fever, weight loss, night sweats, joint pain, rash, preceding URTI)
- Relevant PMH, drug Hx (anticoagulants, NSAIDs), smoking, occupation, FHx
Examples (choose ONE that fits the simulated patient):
- "To find out the cause of blood in the urine"
- "Worried about possible kidney/bladder cancer"
- "Blood in urine is worsening / not stopping"
- ⚠️ The RFC may be fear-driven (e.g. "My father just died of bladder cancer") rather than symptom-driven. Listen for the hidden agenda.
| Component | Example Wording |
|---|---|
| Ideas | "Patient thinks it may be due to kidney stones / infection / cancer" |
| Concerns | "Patient is worried it could be cancer / worried about needing surgery / worried about kidney failure" |
| Expectations | "Patient wants an investigation (ultrasound/urine test) to find the cause / wants reassurance / wants a referral to specialist" |
Depends on the stem. High-yield FM station scenarios:
| Scenario | Most Likely Diagnosis | Minimum Supporting Evidence |
|---|---|---|
| Older male, smoker, painless gross haematuria, weight loss | Bladder cancer [2][5] | Painless, gross, total haematuria + smoking + age > 50 |
| Young adult, cola-coloured urine after URTI, no clots | IgA nephropathy [3][4] | Synpharyngitic haematuria, smoky/cola urine, no clots, ± proteinuria |
| Female, dysuria, frequency, suprapubic pain | UTI / acute cystitis | Dysuria + frequency + +ve dipstick nitrites/leukocytes |
| Colicky loin-to-groin pain + haematuria | Nephrolithiasis | Sudden severe colicky pain radiating to groin + haematuria |
| DDx | Key Discriminator |
|---|---|
| Bladder cancer | Painless gross haematuria + smoking + age > 50; weight loss [2] |
| Renal cell carcinoma | Flank mass, haematuria, flank pain; ± paraneoplastic (polycythaemia, hypercalcaemia) |
| UTI | Dysuria, frequency, urgency, fever, +ve urine culture |
| Nephrolithiasis | Colicky loin-to-groin pain; stone on imaging |
| IgA nephropathy | Synpharyngitic haematuria, cola-coloured, dysmorphic RBCs, RBC casts [3][4] |
| Glomerulonephritis (other) | Proteinuria + haematuria + ↑BP + oedema + ↑Cr (nephritic syndrome) [7] |
| BPH / prostate Ca | LUTS + older male + DRE findings |
(Pick the 3 most relevant to the stem you are given.)
| Domain | Example Problem |
|---|---|
| Biological | Haematuria requiring investigation to exclude malignancy; anaemia from chronic blood loss |
| Psychological | Anxiety/fear about cancer diagnosis; sleep disturbance from worry |
| Social/Functional | Time off work for investigations; impact on family (financial, caregiving); smoking cessation needed if bladder Ca risk |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports |
|---|---|---|---|
| Bladder cancer | Palpable suprapubic mass (if advanced / clot retention) | Abdominal palpation; bimanual exam | Suggests large tumour or clot retention [2] |
| Renal cell carcinoma | Ballotable flank/loin mass | Bimanual ballottement in flank | Renal mass; present in ~25% at presentation |
| UTI | Suprapubic tenderness | Palpation of suprapubic area | Indicates bladder inflammation |
| Nephrolithiasis | Renal angle tenderness | Percussion over costovertebral angle | Suggests ureteric obstruction / pyelonephritis |
| IgA nephropathy / GN | Peripheral oedema + hypertension | BP measurement; pitting oedema check | Features of nephritic syndrome [7]; note: may have NO physical sign in isolated haematuria — then state "urine dipstick with blood and protein is the best bedside clue" |
| BPH / prostate Ca | Enlarged or hard/nodular prostate on DRE | Digital rectal examination | BPH = smooth, firm, enlarged; Ca = hard, irregular, nodular |
| Glomerulonephritis (general) | Periorbital/pedal oedema + raised BP | Inspection + BP | Nephritic syndrome features [7] |
For isolated glomerular haematuria (e.g. TBMD, early IgA nephropathy), there may be no reliable physical sign in a brief FM station. State this explicitly and note that urine microscopy showing dysmorphic RBCs/RBC casts is the best investigation clue [4].
Must-Not-Miss Red Flags
- Painless gross haematuria in a smoker > 50 = bladder/urothelial cancer until proven otherwise [2][5]
- Haematuria + haemoptysis = pulmonary-renal syndrome (anti-GBM / Goodpasture) → urgent referral [7]
- Haematuria + rapidly rising creatinine = rapidly progressive GN → urgent nephrology referral
- Clot retention with inability to void → urological emergency (three-way catheter + irrigation) [2]
- Any gross haematuria with haemodynamic instability → resuscitate + urgent urology
Common Exam Traps
- Forgetting to ask about stream timing (initial/terminal/total) — this is a key discriminator between urethral, bladder, and upper-tract sources [1].
- Assuming anticoagulant use explains haematuria — anticoagulants may unmask an underlying lesion; always investigate.
- Missing IgA nephropathy — the classic synpharyngitic (concurrent with URTI, not post-streptococcal 10–21 days later) pattern is a favourite exam question [3][4].
- Confusing post-streptococcal GN vs IgA nephropathy: Post-strep = haematuria 1–3 weeks AFTER pharyngitis + low C3; IgA = haematuria CONCURRENT with URTI + normal C3 [4][7].
- Not asking about occupation/chemical exposure for bladder cancer risk.
- Dipstick positive for blood but no RBC on microscopy = myoglobinuria (rhabdomyolysis) or haemoglobinuria, NOT haematuria [8].
- Forgetting ICE and RFC — these are high-mark items on the CRF.
Shortest Safe Management / Safety-Net Line
「如果突然痾好多血、痾唔到尿、頭暈、發燒，要即刻去急症室。」 ("If you suddenly pass a lot of blood, can't urinate, feel dizzy, or have fever, go to A&E immediately.")
Investigations to mention: urine dipstick + microscopy, urine culture, bloods (RFT, CBC), renal tract ultrasound [9]. Referral to urology (if suspected malignancy/stones) or nephrology (if suspected GN).
High Yield Summary
What to ASK: Stream timing, colour/clots (glomerular vs urological), pain, LUTS, preceding URTI (IgA), weight loss, smoking, occupation, drugs, FHx of renal disease/deafness, and ICE.
What to WRITE on the CRF: Chief complaint with full HPI characterisation; ONE clear RFC (often fear of cancer); ICE; most likely diagnosis with minimum 3 supporting features; 3 DDx each with a discriminator; biopsychosocial problems; and the best physical sign.
What NOT TO MISS: Painless haematuria in smoker > 50 = cancer workup. Synpharyngitic haematuria = IgA nephropathy. Haematuria + haemoptysis = pulmonary-renal syndrome → urgent. Dipstick +ve / microscopy -ve = not true haematuria (myoglobinuria/haemoglobinuria).
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: Case 4 - Haematuria.pdf (p2 – learning objectives, pattern of haematuria in relation to different diagnoses) [2] Past papers: 2020 Fourth Summative Minicases.pdf (p14-22 – haematuria case: bladder cancer, workup, smoking, painless haematuria) [3] Senior notes: Block A - Nephrology Interactive Tutorial.pdf (p1 – nephritic syndrome, IgA nephropathy, synpharyngitic haematuria) [4] Senior notes: Ryan Ho Fundamentals.pdf (p358 – isolated glomerular haematuria, IgA nephropathy, Alport syndrome, TBMD) [5] Senior notes: Maksim Medicine Notes.pdf (p229 – haematuria definitions, workup for suspected GN) [6] Senior notes: Ryan Ho Rheumatology.pdf (p70 – lupus nephritis presenting with haematuria/proteinuria) [7] Senior notes: Block A - Glomerular and Tubulo-interstitial Diseases and Acute Kidney Injury.pdf (p8 – asymptomatic haematuria, dysmorphic RBCs); Block A – Nephrology Data Interpretation.pdf (p17 – GN clinical presentation table) [8] Senior notes: Ryan Ho Neurology.pdf (p196 – rhabdomyolysis: dipstick +ve, microscopy -ve for haematuria) [9] AOS material: AOS - Radiology.pdf (p36, 39 – painless haematuria workup: ultrasound, plain CT, contrast CT)
Haematemesis
Haematemesis is the vomiting of blood, originating from the upper gastrointestinal tract, indicating conditions such as peptic ulcers, variceal bleeding, or mucosal erosions.
Haemoptysis
Haemoptysis is the coughing up of blood or blood-stained sputum originating from the lower respiratory tract.