Hematuria
Hematuria is the presence of red blood cells in the urine, which may be visible (gross) or detectable only microscopically, indicating potential urinary tract pathology.
History Taking: Hematuria (血尿)
1. Presenting Complaint Framework
The structured approach to hematuria essentially asks four key questions sequentially. Get these right and you've framed the entire case.
This is the first thing to establish. Not all red urine is bloody urine. [1][2][3]
- Ask about dipstick and microscopy results if available
- "Have you had any urine tests done already? What did they show?"
- (你有冇驗過小便？結果係點？)
- Exclude mimics [1][3]:
- Menstrual blood contamination (月經污染) — ask females about timing relative to period [2]
- Myoglobinuria / haemoglobinuria (肌紅蛋白尿 / 血紅蛋白尿) — ask about strenuous exercise, dark urine after exertion, muscle pain [1]
- Food pigments: beetroot (紅菜頭) [1][3]
- Drug-induced: rifampicin (橙色), levodopa (深色), senna, pyridium, phenytoin [1][2][3]
- Diseases: porphyria, alkaptonuria, bilirubinuria [1]
Why this matters: A student who dives into the differential without first confirming it's actual hematuria will lose easy marks. The dipstick detects heme (peroxidase activity), so it can be false-positive with myoglobin or haemoglobin. Always confirm with microscopy. [1]
This is the single most important branch point. Ask about colour, clots, and frothy urine. [1][2]
| Feature | Extraglomerular (Surgical) | Glomerular (Medical) |
|---|---|---|
| Colour | Red or pink (紅色/粉紅色) | Smoky brown, 'Coca-Cola' (茶色/可樂色) |
| Clots (血塊) | May be present; may be vermiform (worm-like) | Absent (urokinase/tPA in glomeruli prevents clot formation) [1][2] |
| Proteinuria | < 500 mg/d | May be >500 mg/d, >2+ on dipstick |
| Urine microscopy | Isomorphic (smooth, round RBCs) | Dysmorphic RBCs, RBC casts [1][2] |
| Frothy urine (泡沫尿) | Absent | May be present (nephrotic-range proteinuria) [2] |
- "What colour was the blood in your urine — bright red, pink, or more like dark tea/Coca-Cola?"
- (你尿入面嘅血係咩色？鮮紅色、粉紅色、定係好似茶色/可樂色？)
- "Did you see any blood clots?"
- (你有冇見到血塊？)
- "Was your urine foamy/frothy?"
- (你嘅小便有冇好多泡？)
Why this matters: Gross hematuria with passage of clots ALWAYS indicates NON-glomerular bleeding [2]. Conversely, the characteristic absence of blood clots in glomerular bleeding is due to the diffuse capillary process plus urokinase and tPA in glomeruli and tubules. [2]
Key Principle
Students commonly forget to ask about clots and urine colour. These two questions alone can dichotomize your differential into medical vs surgical causes — this is the highest-yield branch point in hematuria history-taking.
The classic teaching (though acknowledged as unreliable in predicting location per lecture slides [3]) still gets asked in OSCEs: [2][3]
| Timing | Suggested Source |
|---|---|
| Initial stream (開始時) | Urethra (membranous and spongy urethra) |
| Whole stream (成條尿都有) | Kidney / Ureter / Bladder |
| Terminal stream (尾段) | Bladder neck / Prostate (prostatic urethra) |
- "When in the stream do you see the blood — right at the start, throughout, or just at the end?"
- (你見到血係喺開始、成條尿都有、定係尾段先有？)
Why this matters: Although the lecture slides note this is unreliable [3], examiners still expect you to ask it. It demonstrates structured thinking about anatomical localization.
2. Detailed Symptom Analysis (SOCRATES + Associations)
Once the four framework questions are answered, systematically flesh out the HPI:
- "How much blood are we talking about — the whole toilet bowl, just a tinge, or was it just found on testing?"
- (有幾多血？成個廁所都係血、定係少少粉紅色？)
- "How many episodes have you had?"
- (發生咗幾多次？)
- "When did you first notice it?" (幾時開始？)
- "Has it been getting worse, staying the same, or come and go?"
- (有冇越嚟越嚴重？定係時有時冇？)
- "Was there anything that triggered it — trauma, exercise, a new medication?"
- (有冇咩嘢令到佢出現？撞親？做運動？食新藥？)
Urological symptoms (泌尿系統症狀):
- Dysuria (排尿痛): "Does it burn or sting when you pass urine?" (排尿嗰陣有冇痛/㗎？) → UTI [3][5]
- Fever (發燒): → UTI / pyelonephritis / urosepsis [2][3]
- Loin/flank pain (腰痛):
- Stone passage (排石): "Did you notice any gritty particles in the urine?" (有冇喺尿入面見到碎石？)
- LUTS — Storage and Voiding symptoms [2][6]:
- Hematospermia (血精): → CA prostate [2]
Autoimmune/Glomerular red flags [4]:
- Recent URTI (最近有冇傷風感冒？): IgA nephropathy (synpharyngitic hematuria — occurs during URTI, not 2-3 weeks after) or post-infectious GN (2-3 weeks after) [2][4]
- Rash: purpuric rash → HSP / GPA; malar rash → SLE [4]
- Arthralgia / myalgia (關節痛/肌肉痛): → SLE, vasculitis [4]
- Epistaxis, rhinorrhoea (流鼻血/鼻水): → GPA (Granulomatosis with Polyangiitis) [4]
- Haemoptysis (咳血): → pulmonary-renal syndrome (Goodpasture's, GPA) [4]
Constitutional symptoms (全身症狀):
- Weight loss (體重下降), anorexia (食慾不振), night sweats (夜間盜汗) → malignancy, TB [2]
- Bleeding tendency (容易瘀/流血): → bleeding diathesis [2][4]
Why ask about URTI?: IgA nephropathy classically presents with gross hematuria during or within days of an URTI (synpharyngitic), while post-streptococcal GN presents 2-3 weeks after. This is a common viva differentiator.
| Condition to Ask About | Why It Matters |
|---|---|
| TB (肺結核) | Renal TB can cause sterile pyuria and hematuria [2] |
| CKD / Hypertension (慢性腎病/高血壓) | Pre-existing renal parenchymal disease [2] |
| Previous malignancy | Recurrence or treatment-related (cyclophosphamide, radiation) [2] |
| Bleeding disorders | Explains hematuria but does NOT exclude underlying pathology [4] |
| Diabetes mellitus | Diabetic nephropathy, increased UTI risk [5] |
| PKD/Hereditary nephritis | Inherited causes of hematuria [2] |
| Connective tissue disease (SLE, vasculitis) | Glomerular causes [4] |
| Recent procedures (尿管/活檢) | Iatrogenic — catheterisation, biopsy, TURP [2] |
Past Surgical History (手術歷史)
- Any urological surgery (e.g. TURP, nephrectomy, lithotripsy)
- Pelvic surgery or radiation (e.g. for CA rectum, CA cervix → irradiation cystitis) [2]
- Gastric bypass / bowel resection (increased oxalate stones) [2]
This is a frequently tested area:
| Drug | Relevance |
|---|---|
| Anticoagulants (e.g. warfarin, DOACs) / Antiplatelets (e.g. aspirin, clopidogrel) | Can unmask underlying pathology; antiplatelet/anticoagulant use is NOT a satisfactory explanation for hematuria except in warfarin overdose [4][3] |
| Cyclophosphamide / Ifosfamide | Haemorrhagic cystitis [2] |
| Ketamine (氯胺酮/K仔) | Ketamine cystitis — important in HK context [5] |
| NSAIDs | Interstitial nephritis, papillary necrosis |
| Rifampicin | Orange/red discolouration — not true hematuria [1][3] |
Common Pitfall
Antiplatelet / anticoagulant use is NOT a satisfactory explanation for hematuria, except in the context of warfarin overdose with supratherapeutic INR. [4] Always investigate further — these drugs may unmask an underlying malignancy. Students who dismiss hematuria as "just from the blood thinners" will lose marks.
Allergies (藥物敏感)
- "Do you have any known drug allergies?" (你有冇藥物敏感？)
- Document specific reaction type (anaphylaxis vs intolerance)
- Polycystic kidney disease (多囊腎) — autosomal dominant [2]
- Hereditary nephritis (Alport syndrome) — X-linked or autosomal [2]
- Urinary stones (尿路結石) — familial tendency [2]
- Vesicoureteral reflux (膀胱輸尿管反流) — relevant in paediatric cases [2]
- Malignancy — particularly urological cancers [3]
- Sickle cell disease — relevant in certain populations (papillary necrosis)
6. Social History (社交史)
- Ketamine / recreational drug use (K仔/毒品) — important in HK [5]
- "Do you use any recreational drugs, including ketamine?"
- (你有冇用過消閒藥物，例如K仔？)
- Exercise — vigorous exercise can cause exercise-induced hematuria [2]
- "Were you doing any heavy exercise before this happened?"
- (之前有冇做劇烈運動？)
- Sexual history (性生活) — STIs, urethritis [2]
- Travel history — schistosomiasis (endemic areas in Africa/Middle East)
- Alcohol (飲酒) — liver disease → coagulopathy
- "Before this, were you managing day-to-day activities independently?"
- (之前你日常生活可唔可以自己搞掂？)
- Mobility, ADLs, continence baseline
- Contamination with menstrual blood should be ruled out by repeating urinalysis after menstruation has ceased [2]
- Cyclic hematuria during and shortly after menstruation suggests endometriosis of the urinary tract [2]
- "When was your last period? Could the blood be from your period?"
- (你上次月經幾時？有冇可能係月經嘅血污染咗？)
Here's a high-yield quick-fire list organized by diagnosis:
| Suspected Diagnosis | Key Differentiating Questions |
|---|---|
| Bladder cancer | Painless gross hematuria? Age >40? Smoker? Occupational exposure? Irritative LUTS? [3][7] |
| Renal cell carcinoma | Flank mass? Weight loss? Haemoglobin drop? Left-sided varicocele (L renal vein obstruction)? [4] |
| Urothelial cancer (upper tract) | Painless? Smoker? Aromatic amine exposure? Previous bladder TCC? [7] |
| Prostate cancer | Obstructive LUTS? Hematospermia? Bone pain? Age? PSA history? [2] |
| BPH | Obstructive LUTS? Nocturia? Age? No weight loss? [2][6] |
| UTI / Pyelonephritis | Dysuria? Fever? Frequency? Urgency? Suprapubic pain? Loin pain? [3][5] |
| Urolithiasis | Severe colicky loin-to-groin pain? Restlessness? Stone passage? Prior stones? [2] |
| IgA nephropathy | Synpharyngitic gross hematuria (during URTI)? Young patient? [2][4] |
| Post-infectious GN | Gross hematuria 2-3 weeks after pharyngitis/impetigo? Oedema? [2] |
| ADPKD | Family history? Flank pain? Hypertension? Bilateral palpable kidneys? [2] |
| Haemorrhagic cystitis | Cyclophosphamide? Ifosfamide? Pelvic irradiation? [2] |
| Ketamine cystitis | Ketamine use? Severe frequency/urgency? Small-capacity bladder? [5] |
| GPA | Epistaxis? Sinusitis? Haemoptysis? Renal impairment? [4] |
This is a commonly tested list [2][7]:
- Age >35 years (some guidelines say >40)
- Smoking history — risk correlates with extent of exposure
- Occupational exposure to chemicals or dyes (benzenes or aromatic amines)
- History of gross hematuria
- History of chronic cystitis or irritative voiding symptoms
- History of pelvic irradiation
- History of exposure to cyclophosphamide
- History of chronic indwelling foreign body
- History of exposure to aristolochic acid
- History of analgesic abuse (increased incidence of carcinoma of the kidney)
| Red Flag | Action |
|---|---|
| Painless gross hematuria in adult | Urgent urology referral + cystoscopy + CT urogram [2][3] |
| Clot retention (unable to void, suprapubic pain, distended bladder) | Emergency — 3-way catheter irrigation [3] |
| Haemodynamic instability (tachycardia, hypotension) from heavy bleeding | Resuscitation → emergency urology consult |
| Signs of urosepsis (fever, rigors, tachycardia + hematuria) | Sepsis 6, IV antibiotics, blood cultures |
| Pulmonary-renal syndrome (haemoptysis + hematuria + renal impairment) | Urgent nephrology/ICU — consider Goodpasture's/GPA |
| New renal impairment with hematuria and proteinuria | Nephrology referral for possible renal biopsy |
| Unexplained hematuria in patient >40 | Must exclude malignancy with full workup [2][3][7] |
Common Mistakes
- Not confirming it's truly hematuria — jumping straight to differentials without excluding menstruation, food, drugs, or pigmenturia.
- Dismissing hematuria in patients on anticoagulants/antiplatelets — these medications do NOT adequately explain hematuria and should NOT prevent full investigation. [4]
- Forgetting to ask about clots — this single question separates glomerular from non-glomerular bleeding.
- Not asking about smoking and occupation — these are the most important modifiable risk factors for urothelial cancer.
- Missing the synpharyngitic pattern — failing to ask about concurrent URTI (IgA nephropathy) vs 2-3 week lag (post-streptococcal GN).
- Not asking about ketamine in Hong Kong patients — ketamine cystitis is a real and locally relevant diagnosis.
- Forgetting menstrual history in female patients.
- Not asking about exercise — exercise-induced hematuria is benign but must be considered.
Exam Tips
- "Painless gross hematuria = malignancy until proven otherwise" — this phrase must appear in your answer. It is the single most important concept. [2][3]
- If the examiner gives you a smoky brown/Coca-Cola coloured urine with no clots → think glomerular. If bright red with clots → think surgical/urological. [1]
- Clots = non-glomerular. Full stop. The examiner may try to trick you — glomerular bleeding does NOT produce clots. [1][2]
- If a patient has hematuria + haemoptysis → pulmonary-renal syndrome (Goodpasture's or GPA). This is a classic OSCE viva question.
- IgA nephropathy = hematuria during URTI. Post-streptococcal GN = hematuria 2-3 weeks after pharyngitis. Know the timing difference.
- Field cancerization — bladder TCC can be multifocal and the entire urothelium is at risk, which is why upper tract imaging is needed alongside cystoscopy. [7]
- Left-sided varicocele in a male with hematuria → think left RCC obstructing the left renal vein. [4]
"Mr Chan is a 65-year-old retired painter and current smoker of 40 pack-years who presented 3 days ago to Queen Mary Hospital with a 2-week history of painless gross hematuria. He describes bright red urine throughout the stream with occasional small blood clots, but no dysuria, fever, flank pain, or stone passage. He reports no frothy urine. He has associated 3 kg unintentional weight loss over the past 2 months but denies night sweats, bone pain, or haemoptysis. He has no lower urinary tract symptoms of obstruction or irritation.
His past medical history includes hypertension controlled on amlodipine 5 mg daily and hyperlipidaemia on atorvastatin 20 mg. He has no history of diabetes, TB, renal disease, or previous malignancy. He has no past surgical history. He takes no anticoagulants or antiplatelets. He has no known drug allergies.
There is no family history of polycystic kidney disease, hereditary nephritis, or urological malignancies.
Socially, he is a 40 pack-year smoker with occupational exposure to chemical dyes for over 20 years as a painter. He drinks alcohol socially and denies any recreational drug use including ketamine. He is independent in activities of daily living.
In summary, this is a 65-year-old gentleman with significant risk factors for urothelial malignancy — including age, heavy smoking history, and occupational chemical exposure — presenting with painless gross hematuria with clots and constitutional symptoms. The leading differential is urological malignancy, most likely bladder cancer, and he warrants urgent cystoscopy with CT urogram. I would also send urine for microscopy, culture and sensitivity, cytology, and check his renal function and full blood count."
Active Recall - History Taking
[1] Senior notes: Ryan Ho Urogenital.pdf (p131) / Ryan Ho Fundamentals.pdf (p341) [2] Senior notes: felixlai.md (Hematuria sections, pp. 764–769; BPH/ADPKD sections) [3] Lecture slides: GC 183. Common urological malignancies and their presentations - Nov 7.pdf (pp. 3–6, 13) [4] Senior notes: maxim.md (Urology — Haematuria section, pp. 308–309) [5] Lecture slides: GC 210. Urinary tract infection.pdf (p23) [6] Senior notes: felixlai.md (BPH and LUTS/IPSS sections) [7] Lecture slides: GC 183. Common urological malignancies and their presentations - Nov 7.pdf (pp. 5, 13); Senior notes: felixlai.md (Urothelial bladder cancer section, pp. 816–817)
High Yield Summary
Hematuria is ALWAYS a red flag — considered malignancy until proven otherwise, especially painless gross hematuria in adults ≥40.
Four-step framework: (1) Confirm it's real hematuria → (2) Medical vs surgical → (3) Localise by stream timing → (4) Painful vs painless.
Clots = non-glomerular. No clots + Coca-Cola urine + dysmorphic RBCs = glomerular.
Never dismiss hematuria because a patient is on anticoagulants — investigate fully.
Must-ask risk factors: Smoking (pack-years), occupation (chemical/dye exposure), cyclophosphamide/radiation history, ketamine use (HK-specific).
Key timing distinction: IgA nephropathy = hematuria during URTI; Post-streptococcal GN = hematuria 2-3 weeks after.
Workup: Cystoscopy (lower tract) + CT urogram (upper tract) for all unexplained hematuria. Urine microscopy, culture, and cytology. Check renal function.
High Yield Summary
Definition: Gross hematuria = visible blood in urine; Microscopic = ≥ 3 RBC/HPF. Always confirm dipstick with microscopy.
Most important cause to exclude: Malignancy — painless gross hematuria in any adult > 35 years is urothelial cancer until proven otherwise.
Blood clots = ALWAYS non-glomerular (urokinase/tPA in glomeruli prevent clotting).
Glomerular vs Non-glomerular: Dysmorphic RBCs/RBC casts = glomerular → nephrology. Isomorphic RBCs = urological → cystoscopy + imaging.
Key risk factors for urological malignancy (must ask): Smoking (pack-years), age > 35, male sex, occupational chemical exposure (rubber, dye, petroleum), aristolochic acid (TCM), cyclophosphamide, prior pelvic radiation, chronic UTI.
Anticoagulants/antiplatelets do NOT explain hematuria (except warfarin OD) — always investigate.
Timing in stream: Initial = anterior urethra; Terminal = bladder neck/posterior urethra; Throughout = bladder/upper tract (but unreliable).
Causes by site (from the lecture slide):
- Kidney: stone, AML, infection, trauma, polycystic kidney, medical causes, RCC
- Ureter: stone, TCC
- Bladder: infection, stone, irradiation cystitis, bladder cancer
- Prostate: BPH, prostate cancer
- Urethra: infection, urethral cancer
Risk stratification (AUA): Low risk → repeat UA in 6 months; Intermediate → cystoscopy + renal USS; High risk → cystoscopy + CT urogram.
High Yield Summary
Framework: Always start with Glomerular vs Non-Glomerular → then sub-classify by anatomical site.
Glomerular DDx (dysmorphic RBCs, RBC casts, proteinuria): IgA nephropathy (most common), thin BM disease, Alport syndrome, post-infectious GN, lupus nephritis, ANCA vasculitis, anti-GBM disease.
Non-glomerular DDx by site (isomorphic RBCs ± clots):
- Kidney: RCC, AML, polycystic kidney, pyelonephritis, TB, renal infarction, papillary necrosis, trauma
- Ureter: Stone, TCC (field cancerization)
- Bladder: CA bladder (most common urinary malignancy), cystitis, stone, irradiation cystitis, haemorrhagic cystitis
- Prostate: BPH, CA prostate, prostatitis
- Urethra: Urethritis, trauma, urethral CA
Most common cause: UTI (~60%). Most worrying: Malignancy — painless gross hematuria in > 35 y/o = urothelial cancer until proven otherwise.
Red flags in "recurrent UTI": Persistent hematuria after treatment → must exclude malignancy with cystoscopy. Sterile pyuria → TB, ketamine cystitis. Recurrent urease-producing organisms → underlying stone.
Bleeding disorders/anticoagulants: NOT a satisfactory explanation — 81% have underlying urinary pathology. Always investigate.
Pseudohematuria: Haemoglobinuria, myoglobinuria (dipstick +ve, no RBCs), drugs/food (dipstick -ve, no RBCs).
High Yield Summary
Step 1 — Confirm true hematuria: Centrifuge → red sediment = true hematuria; red supernatant + dipstick +ve = haemoglobinuria/myoglobinuria; red supernatant + dipstick -ve = drug/food/porphyria.
Step 2 — Characterise: Urine microscopy → dysmorphic RBCs / RBC casts = glomerular → nephrology. Isomorphic RBCs ± clots = non-glomerular → urology.
Step 3 — Exclude UTI first (MSU C/ST). If hematuria persists after treating UTI → full workup.
Step 4 — Risk stratify (AUA 2020 for microscopic hematuria): Low → repeat UA in 6 months; Intermediate → cystoscopy + renal USG; High → cystoscopy + CT urogram.
Gross hematuria: Always gets full workup — cystoscopy + CTU ± urine cytology × 3.
CTU has 3 phases: Non-contrast (stones), nephrographic (renal masses), excretory (urothelial lesions).
Cystoscopy: Only modality that can detect papillary TCC as small as 1 mm and CIS. Non-invasive tests CANNOT replace cystoscopy for bladder CA diagnosis.
Urine cytology: High specificity ( > 98%) but low sensitivity (~50% overall); best for high-grade TCC and CIS; send fresh, 2nd void, 3 consecutive days.
Glomerular workup: Complement (C3/C4) is the branch point → ↓complement = IC-mediated GN (lupus, PSGN, MPGN); normal complement = non-IC GN (IgAN, ANCA vasculitis, anti-GBM). Renal biopsy for definitive diagnosis.
Renal biopsy indications: Proteinuria > 1 g/day, rising creatinine, active sediment with persistent hematuria.
Refer to nephrology when: Urological cause excluded, ↓GFR, significant proteinuria, young + HTN + isolated hematuria, visible hematuria with URTI.
High Yield Summary
Emergency hematuria: ABC → large-bore 3-way catheter → manual clot evacuation → CBI with NS → urgent rigid cystoscopy if fails → angioembolisation for upper tract bleeding.
Management principle: Hematuria is a symptom — find and treat the cause. Medical causes → nephrologist; Urological causes → urologist.
Glomerular pathway: ACEI/ARB for ALL GN (↓intraglomerular pressure → ↓proteinuria → renoprotective). Specific immunosuppression guided by renal biopsy histology. Lupus nephritis treatment is determined by ISN/RPS class, not just clinical presentation.
Bladder cancer: TURBT for NMIBC ± intravesical BCG; radical cystectomy ± neoadjuvant chemo for MIBC. Cystoscopy/TURBT can NEVER be replaced by non-invasive tests.
RCC: Partial nephrectomy for T1 (preserves renal function); radical nephrectomy for T2+; immunotherapy (ipilimumab + nivolumab) for metastatic poor/intermediate risk.
Urolithiasis: NSAIDs first-line for pain (also ↓ureteral spasm); MET with tamsulosin for 5–10 mm distal ureteric stones; urgent decompression (PCN or JJ stent) if sepsis/AKI; surgical choice depends on stone site and size (ESWL for small renal/upper ureteric, URS for ureteric, PCNL for large renal).
BPH: Surgical indications = complications (refractory AROU, recurrent UTI, recurrent hematuria, renal insufficiency, bladder stones). TURP gold standard. Monopolar uses glycine (risk of TUR syndrome); bipolar uses NS (safer).
3-way catheter: For hematuria with clot formation → allows CBI. Suprapubic catheter if urethral catheterisation contraindicated/failed.
Negative workup: Monitor RFT + urinalysis yearly; re-investigate if new symptoms or risk factors emerge.
High Yield Summary
Complications of hematuria itself:
- Clot retention = most important acute complication → AROU → needs 3-way catheter + CBI ± cystoscopic clot evacuation
- Anaemia from chronic blood loss → check CBC; iron deficiency suggests ongoing occult bleeding
- Clot colic from upper tract bleeding → vermiform clots obstruct ureter → mimics renal colic
Complications of underlying causes:
- Bladder cancer: hydronephrosis (distal ureteric obstruction), fistulae (vesicocolic → pneumaturia; vesicovaginal → incontinence), metastasis (liver, lung, bone), recurrence (field cancerisation → lifelong cystoscopy surveillance)
- Urolithiasis: urosepsis (obstructed + infected = emergency), pyonephrosis, hydronephrosis, obstructive AKI
- GN: progressive CKD, nephrotic complications (VTE, infection), RPGN
- BPH: AROU, chronic retention, UTI, bladder stones, obstructive uropathy, post-obstructive diuresis
Iatrogenic complications:
- TURP: TUR syndrome (hyponatraemia from glycine absorption — monopolar only), retrograde ejaculation (65–75%), bleeding
- TURBT: bladder perforation, obturator nerve reflex
- Nephrectomy: bleeding, CKD (radical > partial)
- Radical cystectomy: high morbidity (30–60%), urinary diversion complications, ED
- Radical prostatectomy: ED (30–80%), urinary incontinence (5–20%)
- ESWL: steinstrasse, perinephric haematoma
- Catheterisation: CAUTI, haemorrhage ex-vacuo, post-obstructive diuresis, transient hypotension
The cost of delay: Single episode of painless gross hematuria in > 35 y/o + risk factors → MUST investigate urgently. Bladder cancer bleeds intermittently — resolution of hematuria does NOT mean resolution of disease.
Hcc/liver Tumours
Hepatocellular carcinoma is the most common primary malignant liver tumor, typically arising in the setting of chronic liver disease and cirrhosis, while other liver tumors include cholangiocarcinoma, hepatoblastoma, and benign lesions such as hemangiomas and hepatic adenomas.
Lower Gi Bleed
Lower gastrointestinal bleeding is hemorrhage originating distal to the ligament of Treitz, most commonly from colonic sources such as diverticulosis, angiodysplasia, or colorectal neoplasms.