# Visible (macroscopic) haematuria - Category: acute - Review status: reviewed (every claim checked against a document named on this page) - Sources: Gross and Microscopic Hematuria - disease-level clinical article (microscopic-haematuria-referral-full.txt) · Schistosomiasis - disease-level clinical article (schistosomiasis-full.txt) · AUA/SUFU Guideline on Microhematuria 2020 - Verified date: 2026-08 ## Verified against - Gross and Microscopic Hematuria - disease-level clinical article (microscopic-haematuria-referral-full.txt) ## Treatment metadata - Urgent urological referral & safety-netting (no drug therapy) ## Complete treatment card ```text VISIBLE (MACROSCOPIC) HAEMATURIA Sources: Gross and Microscopic Hematuria - disease-level clinical article (microscopic-haematuria- referral-full.txt) · Schistosomiasis - disease-level clinical article (schistosomiasis- full.txt) · AUA/SUFU Guideline on Microhematuria 2020 Review status: REVIEWED against the source listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (6) - Blood in the urine the patient can see - the urine looks red or pink [blood in the urine] - Brown or tea-coloured urine counts too, from oxidation of heme pigments, and patients do not always call it blood - Painless visible blood is the presentation that matters most, because visible blood signals significant urological disease whether or not anything else hurts - Terminal haematuria - blood at the end of the stream - is the characteristic complaint of urinary schistosomiasis, which is a leading cause in Egypt [blood in the urine] - Ask about recent urological surgery or instrumentation, a urinary tract infection, or passing a kidney stone - each can explain it - Men with schistosomiasis may also report blood in the semen SIGNS - what you find (4) - A flank mass on examination points to a renal cause and raises the urgency - Check the blood pressure - hypertension alongside haematuria shifts suspicion toward glomerular disease [blood in the urine · hypertension] - Red flag: visible blood automatically places the patient in the high-risk category, and above 35 years it warrants imaging, cytology and cystoscopy to exclude malignancy - Red flag: joint pains, mouth ulcers or a rash alongside haematuria suggest a systemic cause rather than a urological one [blood in the urine · mouth ulcers · rash] TESTS (6) - Ask what goes with it, as a history prompt rather than a presenting feature: back pain, flank pain, unexplained fever, weight loss, loss of appetite, leg swelling or lower abdominal pain - Microscopy first: a strongly dipstick-positive sample with no red cells under the microscope is not bleeding at all but myoglobinuria, haemoglobinuria or another pseudohaematuria - Serum creatinine, and urine protein - proteinuria alongside blood points at the kidney rather than the bladder - Urine microscopy for schistosome ova where there is any freshwater exposure history - Full evaluation is imaging, urine cytology and cystoscopy; ultrasound alone does not clear the bladder - Repeat the urinalysis after any infection has been fully treated, rather than accepting the infection as the answer IF NOT THIS - what else fits (6) - Microscopic haematuria - a dipstick finding, a different card, and a much lower cancer risk - Pseudohaematuria from food or drugs - beetroot, blackberries, fava beans, rifampicin, phenazopyridine, nitrofurantoin, metronidazole and others colour urine without any blood - Rhabdomyolysis or haemolysis, where the pigment is myoglobin or haemoglobin and not red cells - Contamination from menstruation, or from rectal or vaginal bleeding, which must be excluded rather than assumed - Urinary schistosomiasis - see its own card; chronic infection is also a route to bladder cancer - Bladder or renal cancer, which is what the referral exists to find Source Gross and Microscopic Hematuria + Schistosomiasis - disease-level clinical articles Status traced to the source above 1. URGENT UROLOGICAL REFERRAL & SAFETY-NETTING (NO DRUG THERAPY)[1st line] Adult Peds Children are the exception to the cancer logic - isolated haematuria in a child generally does well, and it is the company it keeps (proteinuria, hypertension, impaired renal function) that points to glomerular disease and a worse outlook. Refer to paediatric nephrology, not to urology, when those are present. Source Gross and Microscopic Hematuria - disease-level clinical article (microscopic- haematuria-referral-full.txt) Why There is no primary-care drug for visible haematuria. The action is referral and the reason is the source's own: visible blood places the patient in a high-risk category regardless of symptoms, and the chance of finding a urinary-tract cancer rises from about 3% with microscopic blood to 10-20% when it is visible. Caution Refer even when the blood has stopped. A single episode that cleared is still visible haematuria and still carries the risk. Refer even when the patient is on an anticoagulant. Anticoagulation does not explain haematuria and does not exclude underlying disease. A urinary tract infection is the commonest benign explanation, but it is only an explanation once treated and the urine has been rechecked and is clear. In Egypt, urinary schistosomiasis is a leading cause and its own source calls visible haematuria the most characteristic presenting symptom of S haematobium infection. Ask about canal or Nile water exposure - see the Schistosomiasis card. Chronic urinary schistosomiasis is a route to bladder cancer, so finding bilharzia does not close the question of malignancy in an older patient. Full evaluation is imaging, urine cytology and cystoscopy - a normal ultrasound alone does not clear the bladder. Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. 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