The patient with hematuria: glomerular or urological
- Topic
Blood in the urine can come from the kidney filters or from anywhere along the urinary tract. A few clues tell them apart and decide the next test.
See it in 3D: Kidneys · Ureters · Urinary bladder
What it is
Hematuria is blood in the urine: visible (gross) or detected only on testing (microscopic, more than about three red cells per high-power field). The first step is to confirm true hematuria, because red urine without red cells can come from foods, medicines, hemoglobin or myoglobin. The second is to decide whether the bleeding is glomerular (kidney filter disease, a nephrology question) or non-glomerular (stones, infection or tumors of the tract, a urology question).
Key facts
- Timing in the stream: blood at the start suggests urethra; at the end suggests bladder neck or prostate; throughout suggests bladder, ureter or kidney.
- Pain: colicky flank pain radiating to the groin suggests a stone; dysuria and frequency suggest infection; painless bleeding raises concern for tumor.
- Color: bright red with clots suggests lower tract bleeding; brown, tea- or cola-colored urine suggests glomerular bleeding.
- Mimics: menstruation, beetroot or other pigments, some medicines, porphyria, hemoglobinuria and myoglobinuria.
- Transient causes: vigorous exercise, fever, trauma or a recent catheter or procedure.
- Risk factors for urothelial cancer: age, smoking, occupational exposure to dyes or chemicals, pelvic radiation, some chemotherapy drugs.
Step by step
- Confirm: repeat urinalysis with microscopy on a fresh sample; exclude menstruation, exercise, recent catheterization.
- Ask about timing in the stream, clots, pain, urinary symptoms and recent infections of the throat or skin.
- Ask about smoking, occupation, anticoagulants, family history of kidney disease or deafness, sickle cell disease.
- Measure blood pressure; look for edema; palpate the kidneys and the bladder; check costovertebral angle tenderness.
- Read the sediment: dysmorphic red cells, red cell casts and protein point to the glomerulus.
- Glomerular pattern: kidney function, protein-creatinine ratio, serology and nephrology referral.
- Non-glomerular pattern: urine culture, imaging of the urinary tract and cystoscopy according to cancer risk.
Glomerular and urological causes of hematuria
| Cause | Source | Clues |
|---|---|---|
| IgA nephropathy | Glomerular | Visible hematuria a day or two after a sore throat; young adult |
| Post-streptococcal glomerulonephritis | Glomerular | Cola-colored urine, edema and hypertension one to three weeks after pharyngitis, longer after skin infection |
| Kidney or ureteral stone | Urological | Colicky flank pain radiating to the groin, restless patient |
| Urinary tract infection | Urological | Dysuria, frequency, urgency, white cells and nitrites |
| Bladder cancer | Urological | Painless visible hematuria, older smoker, clots |
| Renal cell carcinoma | Kidney, non-glomerular | Flank pain or mass, weight loss; often found by imaging |
| Myoglobinuria (pseudohematuria) | Not true hematuria | Dark urine, muscle pain after crush, exertion or seizures; dipstick positive, no red cells |
Clinical notes
- Visible hematuria with clots and inability to void (clot retention) needs urgent bladder drainage.
- Hematuria with rising creatinine, hypertension and edema suggests a rapidly progressive glomerulonephritis: urgent nephrology referral.
- Hematuria in a patient on anticoagulants still needs evaluation; anticoagulation can unmask an underlying lesion.
- Persistent microscopic hematuria in an adult with risk factors needs imaging and cystoscopy even without symptoms.
- Hematuria with fever, chills and flank pain suggests pyelonephritis or an infected obstructed kidney.
In the lab
- Urinalysis with microscopy, ideally repeated; urine culture.
- Serum creatinine, estimated glomerular filtration rate and urine protein-creatinine ratio.
- Ultrasound or CT urography of the kidneys and urinary tract; cystoscopy for adults with risk factors or visible hematuria.
- If glomerular: complement levels, antinuclear antibodies, antistreptococcal antibodies, hepatitis and HIV serology, and kidney biopsy when indicated.
Test yourself
Think of the answer, then tap the question to see it.
How many red cells per high-power field define microscopic hematuria?
More than about three red cells per high-power field on urine sediment.
Which sediment findings show that the blood comes from the glomerulus?
Dysmorphic red cells and red cell casts, usually with proteinuria.
A dipstick is strongly positive for blood but microscopy shows no red cells. What should be suspected?
Myoglobinuria from rhabdomyolysis or hemoglobinuria from hemolysis.
What does painless visible hematuria in a 65-year-old smoker suggest?
A urothelial tumor, above all bladder cancer, until proven otherwise; it needs imaging and cystoscopy.
Connections
See it in 3D3
The structures of Durgical's 3D anatomy where it is found.
Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.
Sources: Urine - bloody (MedlinePlus Medical Encyclopedia, U.S. National Library of Medicine, 2025); Hematuria (MSD Manual Professional Edition, 2025).
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Representative model, for educational purposes only.