CT urography and imaging of haematuria

What it is

Haematuria may be visible (gross) or found only on microscopy. Visible haematuria and microscopic haematuria in people at higher risk of cancer (older age, smoking, occupational chemical exposure) need the upper tract imaged and the bladder seen directly. CT urography is the usual upper-tract test: a scan without contrast, then a nephrographic phase that shows renal masses, then a delayed excretory phase in which contrast fills the collecting systems, ureters and bladder so small tumours appear as filling defects. Cystoscopy is still needed because CT misses small, flat bladder lesions. Ultrasound is the choice for low-risk patients, in pregnancy and when contrast cannot be given; MR urography is an option when iodinated contrast is contraindicated.

What to check

• Check every phase: non-contrast (stones, baseline density), nephrographic (renal masses) and excretory (urothelium).
• A renal mass that clearly enhances after contrast is solid until proven otherwise; renal cell carcinoma is the main concern.
• Urothelial carcinoma: a filling defect or wall thickening in the renal pelvis, ureter or bladder on the excretory phase.
• Hydronephrosis without a stone needs the ureter followed down to find a tumour, stricture or outside compression.
• Look outside the urinary tract: nodes, liver, bones and lung bases for spread and other findings.

Reading it step by step (and why)

1. Confirm the indication and phases — visible or high-risk haematuria justifies the extra radiation of several phases.
2. Check kidney function and contrast history before the scan — iodinated contrast needs adequate renal function and a plan for prior reactions.
3. Read the non-contrast phase for stones and baseline density of any renal lesion — later enhancement is measured against it.
4. Read the kidneys in the nephrographic phase for masses and cysts — solid enhancing tissue suggests renal cell carcinoma.
5. Follow each collecting system and ureter from kidney to bladder on the excretory phase — filling defects or thick walls suggest urothelial tumour.
6. Inspect the bladder wall and lumen, aware CT misses small flat lesions — cystoscopy is still needed.
7. Survey nodes, liver, bones and lung bases — staging and other causes of bleeding.

Common mistakes

• Exclude benign causes first: urinary infection, menstruation and vigorous exercise; treat and repeat the urine test.
• A normal CT urogram does not replace cystoscopy in visible haematuria.
• Anticoagulants do not explain haematuria by themselves: patients on them still need the full work-up.
• Haematuria with protein, red-cell casts or rising creatinine points to the kidney filter (glomerular disease): refer to nephrology, not only urology.
• CT urography gives several times the radiation of a single abdominal CT; split-bolus techniques combine phases to reduce it.

Next step

• Visible haematuria or high-risk microscopic haematuria: CT urography plus cystoscopy, with urology referral.
• Low-risk microscopic haematuria, pregnancy or young patient: renal ultrasound plus cystoscopy as advised by urology.
• Poor kidney function or a past severe contrast reaction: ask the radiologist about MR urography or ultrasound with retrograde pyelography.
• Signs of glomerular disease (protein, casts, raised creatinine): refer to nephrology.

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Educational content; it does not replace a radiologist's report and is not a clinical instruction. Each study is ordered on the patient's assessment and your institution's protocols.

Sources: Gross and Microscopic Hematuria (StatPearls (NCBI Bookshelf), 2025); Ultrasound of the Urinary Tract (StatPearls (NCBI Bookshelf), 2025).

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