Urgent urology & nephrology evaluation
Hematuria (Blood in Urine) — Causes, What It Means, and When to See a Specialist
Blood in the urine — whether you can see it (visible or gross hematuria) or it is found only on a urine test (microscopic hematuria) — is a symptom that must be investigated. It is never normal. In many cases it has a benign explanation, such as a urinary tract infection or a kidney stone passing through the ureter. But in a significant proportion of cases — particularly in adults above 40 and in anyone with visible blood — hematuria is the first and sometimes only sign of a serious condition: kidney cancer, bladder cancer, glomerulonephritis, or upper urinary tract tumour.
The most dangerous thing a person can do with blood in the urine is wait and see if it goes away. Haematuria from bladder cancer is frequently intermittent — it appears, disappears, and appears again weeks later. Each disappearance creates a false reassurance. By the time it reappears and is finally investigated, the cancer may have advanced from the muscle-non-invasive to the muscle-invasive stage, transforming a highly curable condition into a far more complex one. At KIMS Secunderabad, visible blood in the urine in any adult is treated as requiring urgent investigation — same-week appointment, not a 6-week wait.
Visible hematuria vs microscopic hematuria
Visible (gross) hematuria. Blood that turns the urine visibly pink, red, or brown. Even a single episode of visible haematuria in an adult requires urgent specialist investigation, regardless of whether it resolves spontaneously. The volume of blood required to colour urine visibly is as small as one millilitre per 500ml of urine — a quantity that has no diagnostic significance in itself but that cannot be ignored.
Microscopic hematuria. Blood detected only on urine dipstick or microscopy — invisible to the naked eye. Found incidentally on routine urine testing, at a GP visit, or on a pre-operative check. Three or more red blood cells per high-power field on urine microscopy is the threshold for clinically significant microscopic haematuria that warrants investigation. Transient microscopic haematuria after vigorous exercise is a recognised phenomenon — persistent microscopic haematuria on two or more urine samples collected at different times is the threshold for urology or nephrology referral.
What causes blood in the urine?
The urinary tract extends from the kidney, through the ureter, into the bladder, and out through the urethra. Blood can originate from any point along this tract. The cause determines the urgency and the direction of investigation — urological causes require cystoscopy and imaging; nephrological causes require kidney biopsy.
Kidney stones
The most common cause of visible haematuria with loin pain. Stone in the kidney or ureter causes bleeding from the mucosal lining. Clue: associated colicky loin pain, history of stones. Investigation: CT KUB. Management at KIMS: RIRS or Mini-PCNL depending on stone size.
Bladder cancer
The most important cause to exclude in visible haematuria in adults above 40. Transitional cell carcinoma of the bladder commonly presents as painless, intermittent visible haematuria. Clue: painless, episodic, particularly in smokers or those with occupational chemical exposures. Investigation: flexible cystoscopy + CT urogram. Management at KIMS: TUR-BT for non-muscle invasive; robotic radical cystectomy (RARC) for muscle-invasive.
Kidney cancer (Renal Cell Carcinoma)
Haematuria is a presenting symptom in approximately 40% of symptomatic kidney cancer cases. Clue: haematuria with flank pain and a palpable mass (the classic triad — now uncommon, as most RCC is detected incidentally). Investigation: CT abdomen with contrast. Management at KIMS: robotic partial or radical nephrectomy.
Upper Tract Urothelial Carcinoma (UTUC)
Transitional cell carcinoma of the renal pelvis or ureter. Presents as painless haematuria. Investigation: CT urogram — the single most sensitive test for UTUC. Management at KIMS: robotic nephroureterectomy.
Glomerulonephritis
Nephrological cause of haematuria — immune-mediated inflammation of the kidney's filtering units. Clue: haematuria with proteinuria, hypertension, and declining eGFR. Red cell casts on urine microscopy are pathognomonic. Investigation: kidney biopsy with full NABL pathology (LM + IF + EM) at KIMS. Management: depends on specific GN subtype.
IgA Nephropathy
The most common primary glomerulonephritis in India. Characteristically presents as haematuria appearing within 24 to 48 hours of a throat infection (synpharyngitic haematuria). Investigation: urine microscopy, kidney biopsy.
Urinary Tract Infection (UTI)
Haematuria with dysuria, frequency, and urgency suggests lower UTI — cystitis. Haematuria with fever and loin pain suggests upper UTI — pyelonephritis. Urine culture confirms the diagnosis. Haematuria in the context of a positive urine culture should still be re-evaluated after antibiotic treatment — if it persists, further investigation for an underlying cause is required.
Benign Prostatic Hyperplasia (BPH)
Enlarged prostate can cause haematuria from congested prostatic veins. Clue: associated urinary obstructive symptoms. Urology review required — haematuria from BPH is a diagnosis of exclusion after bladder and upper tract malignancy has been excluded.
Renal Cyst / Polycystic Kidney Disease
Bleeding into a renal cyst causes haematuria. Usually visible haematuria with loin pain. Investigation: CT abdomen.
Anticoagulant therapy
Warfarin, apixaban, and other anticoagulants lower the threshold for haematuria from an underlying cause. Haematuria in an anticoagulated patient must still be investigated — anticoagulation does not cause haematuria; it uncovers a pre-existing bleeding source.
Exercise-induced haematuria
Vigorous exercise (particularly long-distance running) can cause transient microscopic haematuria — related to bladder trauma or post-exertional muscle breakdown (myoglobinuria, which mimics haematuria on dipstick but contains no red cells on microscopy). This is a diagnosis of exclusion: persistent haematuria after exercise deserves investigation.
The investigation pathway at KIMS
The investigation of haematuria at KIMS follows a systematic approach based on whether the cause is likely urological (bladder, ureter, kidney tumour, stone) or nephrological (glomerular, tubular). In practice, both pathways are often explored in parallel.
Urine dipstick and microscopy
Confirms haematuria, identifies red cell casts (suggesting glomerulonephritis), detects protein (suggesting nephrological cause), and identifies infection (urine culture if positive).
Urine cytology
Examination of shed cells in the urine for malignant cells. Useful for detecting high-grade urothelial carcinoma, though sensitivity for low-grade tumours is limited.
Blood tests
Serum creatinine and eGFR (kidney function), full blood count, coagulation screen if relevant, PSA (in men above 50), ANA and ANCA (if glomerulonephritis is suspected).
Ultrasound of kidneys and urinary tract
Identifies stones, renal masses, hydronephrosis, and bladder wall thickening. Available immediately at KIMS.
CT urogram
The most important investigation for upper tract haematuria. Identifies stones, renal masses, urothelial tumours of the renal pelvis and ureter, and structural abnormalities. Performed with contrast in three phases (non-contrast for stones, nephrographic, excretory for urothelial tumours).
Flexible cystoscopy
Direct visual examination of the bladder lining using a thin flexible endoscope passed through the urethra. The gold standard for detecting bladder tumours. Performed as an outpatient procedure under local anaesthesia at KIMS. Mandatory for all adults with visible haematuria after CT urogram.
Kidney biopsy (if glomerulonephritis suspected)
Ultrasound-guided, NABL-accredited pathology (LM + IF + EM) at KIMS — the full diagnostic workup required for accurate classification of glomerular disease.
Visible blood in the urine — even a single episode, even without pain, even if it resolved within hours — must be investigated with a same-week urology review and imaging. Do not wait. Do not assume it was a UTI without a urine culture confirming infection. Do not assume it will not recur. Call KIMS on 040-4488-5000 for an urgent appointment.
When haematuria is a nephrology problem vs a urology problem
The distinction matters because the investigation and treatment are completely different. At KIMS, both nephrology and urology teams evaluate haematuria simultaneously where the cause is not immediately clear — so a glomerulonephritis is not missed by defaulting to urology, and a bladder cancer is not missed by defaulting to nephrology.
Suggests nephrology (glomerular origin)
Microscopic haematuria with significant proteinuria (PCR above 100 mg/mmol)
Red cell casts on urine microscopy — pathognomonic of glomerulonephritis
Haematuria with declining eGFR or elevated creatinine
Haematuria with hypertension and oedema (nephritic syndrome)
Haematuria appearing within 24–48 hours of throat infection (IgA nephropathy pattern)
Young patient with family history of kidney disease or deafness (Alport syndrome)
Suggests urology (urological origin)
Visible haematuria — particularly painless and intermittent
Haematuria with clots (clots form in the bladder or collecting system — not in the glomerulus)
Haematuria with lower urinary tract symptoms (dysuria, frequency, urgency)
Haematuria with loin pain (suggests stone or collecting system tumour)
Haematuria in a patient above 40 with no other explanation (bladder or kidney cancer must be excluded)
Haematuria with obstructive urinary symptoms (suggests BPH or urethral pathology)
At KIMS, haematuria is evaluated by both the nephrology and urology teams simultaneously where the cause is not immediately clear. The KIMS team does not default to urology and miss a glomerulonephritis — or default to nephrology and miss a bladder cancer. Both specialities review the investigation results and determine the correct management pathway.
Book a Haematuria Assessment at KIMS
Frequently Asked Questions — Hematuria
Not always — but it must always be investigated to determine whether it is serious. The most common causes of visible haematuria are kidney stones and urinary tract infections, both of which are benign and treatable. However, painless visible haematuria in an adult above 40 is bladder cancer until proven otherwise, and this investigation cannot be deferred. Microscopic haematuria (found only on urine testing) has a lower probability of malignancy but still requires systematic investigation. At KIMS, every adult with haematuria receives a structured assessment — the goal is to confirm the cause, not to assume it is benign.
Yes — immediately. Bladder cancer characteristically causes intermittent visible haematuria that disappears and returns. The disappearance is not resolution — it is the tumour bleeding from different areas at different times. A single episode of visible haematuria in an adult, however brief, however completely resolved, requires same-week specialist investigation. The fact that it has gone away is not reassuring — it is the typical pattern of a condition that must be excluded. Call KIMS on 040-4488-5000.
Certain foods can discolour urine in a way that mimics haematuria — beetroot, blackberries, and rhubarb can cause pink or red urine in some people. This is pseudohaematuria — no actual blood is present. The distinction is confirmed by a urine dipstick and microscopy: true haematuria shows red blood cells; food-related discolouration shows none. If you are uncertain whether the red urine you have observed is blood or food-related, a urine test at any laboratory or at KIMS will confirm this within minutes. Do not assume food is the cause without testing.
Painless haematuria is the more concerning pattern, not the less concerning one. Painful haematuria (loin pain with blood, or dysuria with blood) has a more obvious explanation — kidney stone or UTI respectively — which, while unpleasant, is usually not malignant. Painless haematuria — particularly visible, painless haematuria in a person above 40 — is the classic presentation of bladder cancer and upper tract urothelial carcinoma. These tumours are often completely painless until they are advanced. Painless haematuria warrants urgent investigation regardless of age.
Haematuria is blood in the urine — intact red blood cells present on urine microscopy. Haemoglobinuria is haemoglobin in the urine from destroyed red blood cells — the urine appears red or brown (like tea or cola) but microscopy shows no intact red cells. Haemoglobinuria occurs in conditions that break down red cells in the bloodstream — haemolytic anaemia, severe sepsis, mismatched blood transfusion, and march haemoglobinuria (from extreme exertion). Myoglobinuria (from muscle breakdown — rhabdomyolysis) similarly colours the urine brown without red cells. Both haemoglobinuria and myoglobinuria indicate serious underlying conditions requiring urgent investigation.
Anticoagulants — warfarin, apixaban, rivaroxaban, dabigatran — lower the threshold for haematuria but do not cause it by themselves. A patient on anticoagulation who develops haematuria requires the same systematic investigation as a patient not on anticoagulation. The anticoagulation uncovers a bleeding source — the bleeding source still needs to be identified. Studies consistently show that haematuria in anticoagulated patients reveals bladder tumours, kidney tumours, and stones at a clinically significant rate. Haematuria in an anticoagulated patient should not be attributed to the anticoagulant without completing a standard haematuria investigation.
At KIMS, you do not need to decide — the haematuria investigation pathway involves both specialities. The first consultation is with the team best suited to the likely cause based on your symptoms: if the haematuria is associated with loin pain, clots, or urinary symptoms, a urologist reviews first; if it is associated with frothy urine, swelling, or elevated creatinine, a nephrologist reviews first. If the cause is unclear, both teams review the investigations together. To book an urgent haematuria assessment, call 040-4488-5000 — the team will direct you to the correct specialist based on your symptoms.
KIMS Secunderabad — combined nephrology and urology haematuria assessment, flexible cystoscopy for bladder evaluation, CT urogram for upper tract, kidney biopsy with NABL LM+IF+EM for glomerulonephritis diagnosis, Da Vinci Xi and X robotic surgery for bladder and kidney cancer if surgery is required. 1,500+ kidney transplants. Pioneer PCNL centre. NABH and NABL accredited. Call 040-4488-5000.