Blood in the Urine (Haematuria): Causes and When It Matters

Urine that looks pink, red or cola-coloured understandably worries most people. Blood in the urine (haematuria) is usually due to a treatable cause, but it is a finding that should always be investigated. In this article you will find the possible causes of blood in the urine, which tests are done and when you should seek help without waiting.

What is haematuria, and what types are there?

Haematuria means that there are more red blood cells in the urine than normal. It appears in two ways:

• Visible (macroscopic) haematuria: The urine looks pink, red or dark brown. Sometimes there are also clots.
• Microscopic haematuria: The colour of the urine is normal; blood is only detected on a urine test.

The dipstick tests used in routine checks can give misleading results. For this reason, when blood is seen on a dipstick test, the result should be confirmed by examining the urine under a microscope.

What causes blood in the urine?

Blood in the urine can come from the kidneys, the ureters, the bladder, the prostate or the urinary channel (urethra). Common causes are:

• Urinary tract infection: Can come with burning, frequent urination and a sudden feeling of urgency. For details, see the urinary tract infection page.
• Kidney or ureteral stones: When a stone moves, it irritates the urinary tract; the bleeding usually comes with pain in the side. You can find treatment options on the kidney stone treatment page.
• Enlarged prostate: The blood vessels in enlarged prostate tissue can bleed from time to time.
• Bladder tumours: Painless, visible bleeding in particular is the most typical sign of bladder cancer. Smoking is the most important known risk factor. For details, see the bladder cancer page.
• Kidney tumours: Most are found by chance without causing symptoms; sometimes they show themselves through blood in the urine.
• Kidney diseases (glomerular diseases): If blood in the urine comes with protein loss, high blood pressure or swelling (oedema), an assessment by a kidney specialist (nephrologist) may be needed.
• Intense exercise and injury: Strenuous exercise such as long-distance running, or blows to the lower back, can cause temporary bleeding.
• Urological procedures: Bleeding may be seen for a while after a catheter, stone surgery or a prostate biopsy.

Does red urine always mean blood?

No. Foods such as beetroot and blackberries, certain medicines and conditions such as muscle breakdown can colour the urine red. In women, menstrual blood mixing with the urine can also be misleading. For this reason, a urine test should be done outside the period and with a properly collected (midstream) sample.

Do the colour and timing of the bleeding give any clues?

The characteristics of the bleeding can give an idea of where it comes from, but they are not enough for a diagnosis on their own. At the consultation, you may be asked the following questions:

• In which part of the urine stream is the blood? Blood seen only at the start of the stream tends to come from the urethra or prostate, blood seen only at the end from the bladder neck, and blood mixed through the whole stream from the bladder, ureters or kidneys.
• What colour is it? Bright red suggests fresh bleeding, while dark brown or cola-coloured urine may suggest older bleeding or a problem in the kidney.
• Are there clots, and what shape are they? Thin, worm-like clots suggest bleeding from the upper urinary tract, while large, irregular clots suggest bleeding from the bladder.
• Is there pain? Bleeding with pain in the side suggests a stone; bleeding with burning and urgency suggests an infection. Painless bleeding, however, must always be investigated in detail.

Making a note of this information before your appointment and, if possible, taking a photo of the bloodstained urine makes the assessment easier.

Is blood in the urine normal for people taking blood thinners?

Blood-thinning medicines make bleeding more likely, but they are not accepted as the only explanation for blood in the urine. In people taking these medicines, bleeding should also be investigated for an underlying stone, infection or tumour. Do not stop the medicine you are taking without talking to your doctor.

Which tests are done for blood in the urine?

The assessment is planned according to whether the bleeding is visible, your age, your smoking history and any other symptoms. Commonly used tests:

1. Urine test and urine culture: Confirm the bleeding and look for infection.
2. Blood tests: Kidney function and, if necessary, clotting values are checked.
3. Ultrasound scan: The kidneys and bladder are assessed without radiation.
4. CT scan (CT urography): Shows the kidneys and ureters in detail, particularly in visible bleeding.
5. Cystoscopy: A direct look inside the bladder with a thin camera. It is the main method for detecting bladder tumours. For information about the procedure, see the cystoscopy page.
6. Urine cytology: In some patients, examination of the cells in the urine may be requested.

When the bleeding is due to an infection, a follow-up test after treatment is important. If the bleeding continues after the infection has been treated, further assessment is needed.

When should you seek emergency care?

If any of the following apply, go to an emergency department without delay:

• There are clots in your urine and you have difficulty passing urine or cannot pass urine at all
• The bleeding comes with fever, shivering and pain in the side
• You have unbearable pain in the side or abdomen
• The bleeding is heavy and symptoms such as dizziness, weakness or palpitations have appeared
• The bleeding started after a blow to the lower back or abdomen

When should you see a urologist?

Even if it is not an emergency, a urological examination should be planned in the following situations:

• If you have had visible bleeding even once, even if it has stopped on its own
• If microscopic bleeding has been found on repeated tests
• If you are over 40, smoke or have smoked in the past
• If you have worked for a long time in industries such as dyes, chemicals or rubber
• If blood in the urine comes with frequent urination, burning or a weaker urine flow

For similar symptoms, you may also want to read our articles on burning when passing urine and kidney pain.

Op. Dr. Mücahit Kabar sees patients in Bursa (Nilüfer), Turkey, at Özel Medicabil Nilüfer Hastanesi (weekdays 08:30–12:00, +90 444 8 112) and Özel Jimer Hastanesi (weekdays 13:00–17:00, +90 444 45 67). Appointments are booked through the hospitals’ online booking pages or appointment lines. Consultations are held in English or Turkish; the hospitals’ international patient departments can arrange interpreters for other languages. If you are travelling from abroad, you can send your questions and reports by WhatsApp to +90 541 622 54 82 before your visit. See the contact and appointment information for details.