Haematuria
Blood in the urine is cancer until proven otherwise — after you've dealt with any clots. Manage the emergency first (clot retention, significant bleeding), then decide on the right referral: urgent suspected cancer pathway for most visible haematuria, nephrology if it looks glomerular. Built for revision, not live patient decisions.
Settle them, and check the basics
clots · bleedingRed flags — what each should make you think
Haematuria on anticoagulants still needs investigating. Anticoagulants unmask bleeding from an existing lesion, so don't blame the warfarin or DOAC and stop there.
First actions
- 📟Bladder scan
- 🩺Three-way catheter
- 🩸Bloods
- 🧪Urine dip + culture
- ↩Review anticoagulation
- ☎Urology
Understand the patient
where is the blood from?Causes
- Urological — bladder cancer, renal cell carcinoma, upper tract urothelial cancer, prostate (cancer or BPH), stones, infection, trauma, radiation cystitis, post-procedure (TURP, biopsy)
- Renal/glomerular — IgA nephropathy, other GN (often with proteinuria, hypertension, AKI, red cell casts)
- Other — anticoagulation (unmasking), exercise, menstruation, beetroot/rifampicin (red urine without blood)
NICE NG12 — suspected cancer referrals (adults)
- Aged 45+ with unexplained visible haematuria without UTI, or visible haematuria persisting/recurring after successful UTI treatment → urgent suspected cancer pathway (bladder/renal)
- Aged 60+ with unexplained non-visible haematuria and either dysuria or a raised WCC → urgent pathway
- Under these ages: non-urgent urology referral or investigation as appropriate
Work A–E — assess and act as you go
The diagnoses you must not miss
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Painful retention with visible haematuria and clots.
Clinical, bladder scan.
Three-way catheter, bladder washout, continuous irrigation, urology.
Heavy bleeding, falling Hb, hypotension (tumour, radiation cystitis, post-op, trauma).
FBC, clotting, imaging.
Resuscitate, reverse anticoagulation, urology (cystoscopy/embolisation).
Haematuria after blunt or penetrating trauma, flank bruising.
CT with contrast (trauma protocol).
Trauma team; most managed conservatively.
Haematuria with proteinuria, hypertension, oedema, AKI, systemic features.
Urine PCR, U&E, ANCA, anti-GBM, complement.
Same-day nephrology.
Investigate — what to order, when, and what it tells you
test with a question in mindUrine
Bloods
Specialist (urology)
How the plan comes together
disposition · handoverhome + urgent referral
Stable, passing urine, no significant drop in Hb: refer via the appropriate pathway, safety-net for retention or heavy bleeding.
admit / urology
Clot retention, ongoing heavy bleeding, AKI, trauma.
Hand over: catheter type, irrigation, Hb, anticoagulation, referral made.
Clear the clots and resuscitate first, then make sure every patient gets the right investigation. Haematuria is a symptom that needs explaining, even on anticoagulants. Nicely done getting here.
Clerking template
copy or downloadHaematuria — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.
Test yourself
active recallCover the answer, say it out loud, then reveal. Retrieval beats re-reading.
0 / 10 knownFrequently asked questions
quick answersWhat are the red flags for haematuria?
- Unable to pass urine, clots — think clot retention
- Shock, falling Hb — think significant haemorrhage
- Trauma — think renal / bladder injury
- Protein + red cell casts + AKI — think glomerulonephritis
- Painless visible haematuria aged 45+ — think urological cancer
- On anticoagulants — think still needs investigation
What is the initial management of haematuria?
- Bladder scan — retention?
- Three-way catheter — for clot retention — washout and continuous irrigation
- Bloods — FBC, U&E, clotting, G&S
- Urine dip + culture — infection, protein
- Review anticoagulation — with senior if bleeding significant
- Urology — clot retention or heavy bleeding
Always alongside senior support and your local guideline.
What diagnoses must you not miss in haematuria?
- Clot retention — can't pass urine
- Major haemorrhage — shock
- Renal trauma — after injury
- Rapidly progressive GN — protein + AKI
Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.
What investigations should a junior doctor order for haematuria?
- Urine — Confirms blood; protein suggests renal.
- Bloods — FBC, U&E, clotting.
- Specialist (urology) — Cystoscopy and imaging (CT urogram or USS).
Admit or discharge: how is the plan decided for haematuria?
- Home + urgent referral — Stable, passing urine, no significant drop in Hb: refer via the appropriate pathway, safety-net for retention or heavy bleeding.
- Admit / urology — Clot retention, ongoing heavy bleeding, AKI, trauma.
Is there a clerking template for haematuria?
Yes — there is a free clerking template for haematuria on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.
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