1. My Clinical Approach
Hematuria is not a diagnosis — it is a symptom. Blood in the urine can originate anywhere in the urinary tract, from the kidney and ureter down to the bladder, prostate and urethra, and its significance depends on whether it is visible or microscopic, whether it is accompanied by pain, infection or clots, and on individual risk factors.
A sound evaluation does not start with “which test should we order?”, but with a series of clinical questions:
- Are there really red blood cells in the urine?
- Is it visible or microscopic?
- Is there pain?
- Is there infection?
- Are there clots?
- Are there signs of kidney/glomerular disease?
- What is this patient's risk of urothelial malignancy?
- What test does this specific patient actually need?
Hematuria work-up must be thorough — but it should not be identical for everyone. This guide is based on the AUA/SUFU Microhematuria guideline (2025 amendment) and the current EAU Guidelines on non-muscle-invasive and muscle-invasive bladder cancer, upper tract urothelial carcinoma, urolithiasis, and urological infections.
2. What Hematuria Actually Is
Hematuria is the presence of red blood cells in the urine. It falls into two very different categories, which are not evaluated the same way:
Gross (Visible) Hematuria
Blood that is visible to the naked eye — pink, red, dark red, or tea-coloured, depending on the amount and source.
Microscopic Hematuria
Urine looks normal, but microscopy reveals red blood cells. Under the current AUA/SUFU guideline (2025), it is defined as >3 red blood cells per high-power field (RBC/HPF) on a properly collected sample.
Gross and microscopic hematuria are not evaluated in exactly the same way. Gross hematuria is always treated as a significant finding, while microscopic hematuria is assessed using risk stratification.
Dipstick ≠ Confirmed Microhematuria
A urine dipstick detects heme activity — which can come from true red blood cells, but also from hemoglobin or myoglobin without corresponding cells.
A positive dipstick for blood is not, by itself, a diagnosis of microhematuria. The current guideline requires confirmation with standard microscopic examination of a urine sample. For the distinction between true hematuria and hemoglobin in the urine, see the article on hemoglobinuria.
3. Urine Colour Is Not a Diagnosis
Red or brown urine does not always mean blood. It helps to distinguish four possible situations:
Hematuria (RBC)
True red blood cells present on microscopy.
Hemoglobinuria
A positive heme trace without corresponding red blood cells on microscopy.
Myoglobinuria
Related to muscle tissue injury (e.g. intense exercise, trauma), not the urinary tract.
Pseudo-hematuria
Colour change from foods (e.g. beetroot), medications, or dyes, without true blood.
Colour alone doesn’t determine the source
The amount and source of bleeding determine the colour — not the colour the cause. Don’t reassure or alarm yourself based on shade alone.
This distinction should never be reassuring in the presence of genuine, visible bleeding — it simply explains why laboratory confirmation is always needed before drawing conclusions.
4. Visible (Gross) Hematuria
Visible blood in the urine can be continuous, intermittent, or a single episode. A single episode of visible hematuria can be diagnostically significant — it clearing up does not mean it does not need evaluation.
Painless Visible Hematuria
Painless visible hematuria is a classic, recognised presentation of urothelial malignancy, particularly bladder cancer. Blood without pain does not automatically mean a cancer diagnosis — other causes remain possible — but it always needs evaluation, precisely because several important urinary tract conditions can be painless.
Hematuria with Pain
Colicky flank/back pain
Makes a stone plausible, without proving it.
Burning / fever
Makes infection or inflammation plausible, without ruling out other causes.
Pain in general
Does not rule out malignancy. A stone or infection should not be diagnosed from symptoms alone.
Blood Clots in the Urine
Clots indicate a significant amount of bleeding within the urinary tract and can cause interrupted urinary flow, difficulty urinating, or acute urinary retention from clots.
Hematuria + clots + inability to urinate = urgent urological evaluation.
Initial, Terminal, or Total Hematuria
Initial
Blood appears mainly at the start of urination.
Terminal
Blood appears mainly at the end of urination.
Total
Blood is present throughout urination.
Historically, the timing pattern gave clues to the likely anatomical source, but it should not be relied upon alone as a definitive localisation tool — modern evaluation is based on the full clinical picture.
5. Microhematuria & Risk Stratification
Microscopic hematuria is often discovered incidentally, since the urine looks entirely normal. The modern approach, per the AUA/SUFU guideline (2025 amendment), follows specific steps:
- Confirm true microhematuria by microscopy of a properly collected sample.
- Look for transient/benign causes (infection, gynaecological source, recent exercise).
- Repeat urinalysis where indicated, after treating any reversible cause.
- Assess risk of urothelial malignancy.
- Select the work-up according to risk.
Low / Very-Low Risk
The current guideline usually recommends a repeat urinalysis within six months, rather than immediate cystoscopy or imaging.
Intermediate Risk
Cystoscopy and renal/bladder ultrasound are recommended. For informed patients wishing to avoid cystoscopy, urine cytology or an approved urinary biomarker can be discussed, always alongside ultrasound.
High Risk
A more complete evaluation of the lower and upper urinary tract is recommended — cystoscopy plus upper-tract imaging (preferably multiphasic CT urography, or MR urography where CT is contraindicated).
Risk stratification combines several factors — age, sex, smoking history and intensity, degree of microhematuria, persistence of the finding, a prior episode of gross hematuria, and other recognised urothelial cancer risk factors — rather than any single factor such as age alone.
Important change in the 2025 amendment: Previously, age over 60 automatically placed a woman in the high-risk group. The current guideline removed this automatic rule for lower-risk women, so that the intensity of the work-up better reflects each patient’s actual risk.
Anticoagulants/antiplatelets do not change the work-up.
Patients taking anticoagulant or antiplatelet medication are evaluated exactly the same way as those who are not. Being on an anticoagulant is not a sufficient reason to dismiss hematuria, and it should never be stopped without instruction from the prescribing physician.
6. Possible Causes
Urinary Tract Infection
Cystitis, pyelonephritis or prostatitis can cause blood in the urine, usually with burning, frequency or fever. Infection can explain the bleeding only if the blood is confirmed to clear after treatment, on a repeat urinalysis.
Kidney or Ureteral Stones
A stone can injure the lining of the urinary tract and cause bleeding, often (not always) with colicky flank pain. Pain plus blood makes a stone plausible, not proven.
Bladder Cancer
Painless, recurrent visible hematuria is a classic presentation of urothelial malignancy, especially in smokers. It needs to be ruled out with appropriate work-up — it does not automatically mean cancer.
Upper Tract Urothelial Cancer
Less commonly, bleeding originates in the renal pelvis or ureter. CT urography plays an important role in evaluating higher-risk patients.
Kidney Cancer
Renal tumours less often present with hematuria today, as most are found incidentally on imaging done for other reasons — but hematuria remains a reason to image the kidneys.
Prostate (BPH or Prostatitis)
Benign prostatic enlargement or inflammation can bleed. BPH should be a documented diagnosis after evaluation, not an automatic explanation for visible blood.
Anticoagulants / Antiplatelets
These can make an underlying bleed more apparent, but are not, by themselves, a sufficient explanation. A patient on anticoagulation is evaluated the same way as anyone else.
Exercise
Strenuous physical activity can occasionally cause transient hematuria. Persistent, recurrent or visible hematuria should not be automatically attributed to exercise.
Trauma
Hematuria after injury to the abdomen, flank or pelvis can indicate urinary tract injury and needs evaluation proportional to the severity of the trauma.
Gynaecological Sample Contamination
Vaginal bleeding can contaminate a urine sample. When uncertain, a properly collected sample away from active bleeding — or a catheterised sample when clinically indicated — is needed, rather than automatically dismissing the finding as menstrual.
7. Could It Come from the Kidney Itself?
Certain findings suggest a possible glomerular or kidney (“medical renal”) cause of the hematuria, rather than a urological one:
- Significant proteinuria alongside the hematuria.
- Dysmorphic red blood cells or acanthocytes on microscopy.
- Red blood cell casts.
- Worsening kidney function.
- High blood pressure.
- Other kidney findings.
Hematuria + significant proteinuria is not simply a “urological finding” — it may need nephrology assessment.
However, when a recognised risk of urothelial malignancy also exists, referral to nephrology does not replace the need for appropriate urological evaluation — the two proceed in parallel, not as alternatives. See also the article on proteinuria (protein in the urine).
8. Which Tests Are Actually Needed
There is no single fixed sequence of tests for every patient. The right test depends on the type of hematuria and the risk profile.
| Test | Question It Answers |
|---|---|
| Urinalysis with microscopy | Confirms whether real red blood cells, white cells, protein, or casts are present. |
| Urine culture | Useful when there is clinical suspicion of infection — not routinely ordered in every asymptomatic patient. |
| Kidney function testing | Detects declining kidney function that can accompany a renal cause. |
| Kidney & bladder ultrasound | Shows hydronephrosis, larger masses, some stones — does not rule out every disease. |
| CT urography | Provides detailed imaging of the upper urinary tract, especially in higher-risk patients. |
| Cystoscopy | Direct visual inspection of the urethra/bladder — answers a different question than imaging. |
| Urine cytology | A selective role in specific clinical situations, not a routine test for everyone. |
Ultrasound
A useful initial tool, but a normal ultrasound does not rule out every cause of hematuria or every lesion of the bladder/upper urinary tract.
CT Urography
Uses radiation and typically contrast. It is not necessary in every low-risk patient with microhematuria — more imaging does not automatically mean better care for every risk group.
Cystoscopy
Usually an outpatient exam performed with a flexible cystoscope under local anaesthetic gel, brief in duration. A normal ultrasound or CT scan does not make cystoscopy unnecessary when it is otherwise indicated.
Cytology & Urinary Biomarkers
Not used routinely in every low- or high-risk patient, and do not replace cystoscopy when it is indicated. Their role is selective, mainly in intermediate-risk patients or with equivocal findings.
9. Patient Journey — Visible Hematuria
- 1Visible blood in the urine
- 2Pain? Fever? Clots? Retention? Trauma?
- 3Emergency features present → immediate clinical evaluation
- 4Clinically stable → history + urinalysis/microscopy ± culture
- 5Risk assessment
- 6Lower tract evaluation + upper tract evaluation, where clinically indicated
- 7Possible findings: infection, stone, prostate condition, bladder lesion, upper-tract lesion, kidney/glomerular cause, or no immediate cause found
- 8Directed treatment / structured follow-up
10. Patient Journey — Microscopic Hematuria
- 1Red blood cells found on urine microscopy
- 2Confirm a properly collected sample
- 3Is there a transient/benign explanation? (infection, gynaecological cause, recent exercise)
- 4Treat the cause where needed + repeat urinalysis
- 5Persistent microhematuria?
- 6Risk stratification per the current AUA/SUFU guideline
- 7Low/very-low risk → repeat testing at 6 months • Intermediate → cystoscopy + ultrasound • High → fuller evaluation of lower & upper urinary tract
- 8Follow-up based on findings
11. Urological vs Possible Renal Clues
More Consistent with a Urological Origin
- Visible bleeding
- Clots
- Stones
- Urothelial cancer risk factors
- Lower urinary tract symptoms
More Consistent with a Glomerular/Renal Origin
- Significant proteinuria
- Dysmorphic red blood cells / acanthocytes
- Red blood cell casts
- Worsening kidney function
- High blood pressure
Some patients need both urological and nephrology evaluation in parallel.
12. When It Is an Emergency
Seek immediate medical evaluation if there is:
- Inability to urinate due to blood/clots
- Heavy, continuous bleeding
- Dizziness, fainting, or signs of hemodynamic compromise
- Fever or chills with urinary symptoms
- Severe flank pain with systemic illness
- Recent major trauma
- Reduced urine output with systemic illness
- Concerning bleeding in a patient on anticoagulation
Simple, asymptomatic microscopic hematuria is not, by itself, an emergency.
13. Your First Visit — What You Will Be Asked
It helps to have information ready about:
14. Myths to Forget
"The blood stopped, so I don't need to be checked"
A visible episode can be intermittent. The colour clearing is not a diagnostic test and does not prove the underlying cause has gone away.
"I'm on a blood thinner, that explains it"
Anticoagulation can make bleeding more apparent, but it should not be accepted automatically as the underlying cause without evaluation.
"It only happened once, it doesn't matter"
A single visible episode can be worth evaluating, without this meaning you should panic.
"I don't have pain, so it must be harmless"
Painless bleeding deserves attention precisely because several important urinary tract conditions can be painless — without this meaning it is always cancer.
"My ultrasound was normal, so the work-up is done"
A normal ultrasound is reassuring for some findings, but it does not rule out every disease of the bladder or upper urinary tract. The need for further work-up depends on clinical risk.
15. Hematuria Evaluation in Rhodes
For patients on Rhodes with visible or persistent microscopic hematuria, the initial urological evaluation at Dr. Marinos Vasilas’ practice is organised around your history, urinalysis findings, and individual risk, to decide whether further imaging, cystoscopy or a different work-up is needed. Being on Rhodes does not change the underlying medical algorithm — it simply allows local clinical evaluation and coordination of next steps when they are needed. You can book an appointment for an evaluation.
16. The Doctor
Dr. Marinos Vasilas, Urologist – Andrologist
Dr. Marinos Vasilas systematically evaluates patients with hematuria, based on the current AUA/SUFU and EAU guidelines, aiming for an individualised work-up matched to each patient’s actual risk.
Meet the Doctor17. The Team
Evaluating hematuria — from urinalysis to cystoscopy or imaging — is organised in collaboration with an experienced urology practice on Rhodes.
Meet Our Team18. Frequently Asked Questions
What is hematuria?
It is the presence of red blood cells in the urine — either visible to the naked eye (gross hematuria) or detectable only under the microscope (microhematuria). Hematuria is a symptom, not a diagnosis.
What is gross (visible) hematuria?
It is blood in the urine that is visible with the naked eye, ranging in colour from pink to red, dark red, or tea-coloured, depending on the amount and source of bleeding.
What is microscopic hematuria?
It is the presence of red blood cells found on urinalysis without any visible colour change. It can only be detected in the laboratory, by microscopic examination of a urine sample.
How many red blood cells count as microhematuria?
Under the current AUA/SUFU guideline (2025 amendment), microhematuria is defined as more than 3 red blood cells per high-power field (>3 RBC/HPF) on a properly collected urine specimen.
Does a positive dipstick mean there is blood in the urine?
Not necessarily. The dipstick detects heme activity, which can come from red blood cells, but also from hemoglobin or myoglobin without corresponding cells. A positive dipstick should always be confirmed by microscopy — it is not, by itself, a diagnosis of microhematuria.
Can urine be red without blood?
Yes. Certain foods (such as beetroot), medications and dyes can change urine colour without any true red blood cells being present. Urine microscopy separates real hematuria from this pseudo-hematuria.
Should I worry if I only saw blood once?
A single episode of visible hematuria can still be diagnostically significant and warrants evaluation, even if it does not recur.
If the bleeding stopped, do I still need to be checked?
Yes, especially if it was visible. The colour clearing is not a diagnostic test — it does not mean the underlying cause was found or has gone away.
What does painless hematuria mean?
Painless visible hematuria is a classic, recognised presentation of urothelial malignancy, which is why it deserves attention — without this meaning it is always cancer.
Could it just be a urinary infection?
Possibly, but hematuria should not be automatically attributed to infection just because there is burning or white cells present. Confirmation that the bleeding has actually cleared after treatment, on a repeat urinalysis, is needed.
Could it be a kidney or ureteral stone?
Yes, stones are a common cause of hematuria, with or without pain. Pain plus blood together make a stone plausible, but imaging is needed to confirm it.
Could it be bladder cancer?
It is one of the possibilities that always needs to be ruled out, especially with painless, recurrent hematuria or in smokers — without hematuria automatically equating to a cancer diagnosis.
Could it be kidney cancer?
Less commonly today, as many kidney tumours are found incidentally. It remains, however, a reason to image the kidney, especially with a relevant family history.
Could it be coming from the prostate?
Yes, benign prostatic enlargement or prostate inflammation can cause hematuria. This diagnosis, however, needs to be documented rather than assumed automatically.
Do anticoagulants cause hematuria?
They can unmask an underlying bleeding source, but are not, by themselves, a sufficient explanation. The same evaluation applies as for a patient not on anticoagulation.
Should I stop my anticoagulant?
Not without guidance from the prescribing physician. Stopping anticoagulation without medical direction can be dangerous.
What do blood clots in the urine mean?
Clots indicate a significant amount of bleeding within the urinary tract and can cause interrupted flow or difficulty urinating. Clots with an inability to urinate are an emergency.
When is hematuria an emergency?
When there are clots with inability to urinate, heavy continuous bleeding, dizziness or fainting, fever with chills, severe pain with systemic illness, recent major trauma, or concerning bleeding in a patient on anticoagulation.
What tests are needed?
The appropriate test depends on the type of hematuria and individual risk — it may include urinalysis with microscopy, urine culture, kidney function testing, ultrasound, CT urography, cystoscopy, or urine cytology.
Does everyone need a CT urogram?
No. CT urography is mainly recommended for higher-risk patients, not as a universal rule for every low-risk microhematuria case.
Does everyone need cystoscopy?
No. Cystoscopy is recommended for intermediate- and high-risk patients, while low/very-low risk patients are usually offered a repeat urinalysis at six months instead.
What does cystoscopy show?
It allows direct visual inspection of the urethra and the inside of the bladder, looking for lesions that imaging may miss. Imaging and cystoscopy answer different questions.
What is CT urography?
It is a specialised CT scan that images the upper urinary tract (kidneys and ureters). It uses contrast and radiation, which is why it is not required for every low-risk patient.
Is a normal ultrasound enough?
A normal ultrasound is reassuring for some findings, but it does not rule out every disease of the bladder or upper urinary tract. The need for further work-up depends on clinical risk.
Is urine cytology needed?
Not for everyone. Cytology is no longer used routinely in the initial evaluation of low- or high-risk patients, but can be used selectively, for example with equivocal cystoscopy findings.
What if the urine culture is positive?
If hematuria is attributed to infection, a repeat urinalysis with microscopy after treatment is needed to confirm the hematuria has actually cleared.
What does hematuria plus proteinuria together mean?
The combination of hematuria with significant proteinuria increases the likelihood of a kidney/glomerular cause and may warrant nephrology input, without removing the need for urological evaluation when malignancy risk is present.
What do dysmorphic red blood cells or acanthocytes mean?
Their presence on microscopy can suggest a glomerular origin of the hematuria and usually leads to further nephrology work-up.
Do I always need a nephrologist?
Not always. Referral to a nephrologist is made when there is suspicion of glomerular/kidney disease (e.g. proteinuria, dysmorphic red cells, reduced kidney function). Urological evaluation for malignancy risk still proceeds in parallel when warranted.
Can strenuous exercise cause blood in the urine?
Yes, occasionally, but persistent, recurrent, or visible hematuria should not be automatically attributed to exercise without evaluation.
How is hematuria evaluated in Rhodes?
Initial urological evaluation at our Rhodes practice is organised around your history, urinalysis findings, and individual risk, to decide whether further imaging, cystoscopy or a different work-up is needed — the underlying medical algorithm is the same wherever it is applied.
Related Topics
Hematuria Evaluation
The right work-up for hematuria is not the same for every patient. The type of hematuria, your age, smoking history, the presence of infection or a stone, urinalysis findings, and other risk factors determine whether simple re-testing is enough or whether further imaging and cystoscopy are needed.
References
- AUA/SUFU Guideline: Microhematuria, 2025 amendment — auanet.org
- EAU Guidelines on Non-muscle-invasive Bladder Cancer 2026 — uroweb.org
- EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer 2026 — uroweb.org
- EAU Guidelines on Upper Urinary Tract Urothelial Cell Carcinoma — uroweb.org
- EAU Guidelines on Urolithiasis 2026 — uroweb.org
- EAU Guidelines on Urological Infections 2026 — uroweb.org
The content of this page is for informational purposes only and does not replace individualised urological evaluation. Hematuria has many possible causes and online information cannot determine the source of a bleed. Do not stop anticoagulant medication without instruction from the prescribing physician. If any emergency signs are present, seek prompt medical evaluation.
