Intermittent Hematuria: Causes and Next Steps

Q: Intermittent Hematuria: Causes and Next Steps

Hello： Visual inspection of urine shows red color, and urinalysis reveals significant red blood cells. <br>Based on personal experience, if you are over 45 years old and have had hematuria without symptoms for 1-2 days, it is important to undergo thorough examination (of course,

Continuation #147180 Hematuria Issues

Hello Doctor: I have been experiencing hematuria for two months, which occurs intermittently, about once or twice a week.
I have undergone multiple urine tests, which consistently showed red blood cells >100, and once I had a white blood cell count around 10.
A renal ultrasound indicated slight enlargement, and I also had an intravenous pyelogram (IVP) that suggested the presence of kidney stones, although it seemed unable to visualize the surface of the kidneys clearly.
I have had X-rays done four to five times, with two instances showing stones (not very clearly).
I would like to know if I should undergo more detailed examinations, such as a CT scan or cystoscopy.

In the past two months, I have experienced acute colicky pain in the left flank and groin twice.
Could this indicate that the pain is caused by kidney stones? Given the prolonged hematuria and the absence of pain (only mild discomfort occasionally in the upper pelvic area), I am concerned about the possibility of bladder cancer.
Could my symptoms be indicative of bladder cancer? I do not have issues with urination or experience pain or burning during urination.
Should I just drink more water to help? Is it possible for stones to remain lodged for such a long time?

GG, 20~29 year old female. Ask Date: 2019/07/05

Dr. Du Shixi reply Urology

Hello: Visual inspection of urine shows red color, and urinalysis reveals significant red blood cells.
Based on personal experience, if you are over 45 years old and have had hematuria without symptoms for 1-2 days, it is important to undergo thorough examination (of course, if there are symptoms, attention should also be paid).
For someone like you who is 24 years old, it depends on the patient's personal preference, as some individuals may experience discomfort in the urethra after a cystoscopy.
If the assessment suggests a low likelihood of finding a tumor, it is up to the patient's choice.
As for CT scans, they have limitations and may not detect very small tumors or stones.
Since an intravenous pyelogram (IVP) has been performed without any obvious ureteral stones, it is suspected that the stones, if present, are likely very small.
If fluid intake is high (more than 2500 cc per day without special reasons, and minimizing sugary drinks), they should be able to pass naturally.
In addition to medication, it is advisable to engage in regular exercise for at least half an hour each day, which should be beneficial.
Furthermore, if urinalysis continues to show red blood cells, even if the urine does not appear red, regular follow-up (approximately every 3 months) is necessary.
Although statistically, a high percentage may not reveal a clear cause, monitoring is still important.

P.S.
There are many causes of hematuria.
In older individuals, it is possible to consider more than two causes, while younger individuals typically consider one cause, often stones or inflammation, with injury also being a possibility.
Wishing you good health (therefore, if your fluid intake is indeed insufficient, the first priority is to increase your water consumption).

Reply Date: 2019/07/05

More Info

Intermittent hematuria, or the presence of blood in urine that occurs sporadically, can be concerning and may arise from various underlying causes. Given your symptoms and the medical evaluations you've undergone, it's essential to consider both the potential causes and the next steps for further investigation.

Possible Causes of Intermittent Hematuria
1. Urinary Tract Stones: Your history of kidney stones, as indicated by the ultrasound and IVP (Intravenous Pyelogram), is a significant factor. Stones can cause intermittent bleeding as they move through the urinary tract, potentially leading to irritation or injury to the lining of the urinary system.

2. Infections: Although you mentioned that your urine tests showed only a few white blood cells, urinary tract infections (UTIs) can sometimes present with hematuria, especially if there is inflammation or irritation in the bladder or urethra.

3. Benign Prostatic Hyperplasia (BPH): In males, an enlarged prostate can lead to hematuria, particularly if it compresses the urethra or causes urinary retention.

4. Bladder or Kidney Tumors: While your concern about bladder cancer is valid, especially given the persistent nature of your hematuria, it is essential to note that tumors often present with other symptoms, such as pain or changes in urinary habits. However, the absence of these symptoms does not entirely rule out malignancy.

5. Trauma or Injury: Any recent trauma to the kidney or bladder area could also lead to intermittent bleeding.

Next Steps for Investigation
Given that you have experienced hematuria for two months, it is advisable to pursue further diagnostic testing to identify the underlying cause. Here are some recommended steps:
1. CT Scan: A non-contrast CT scan of the abdomen and pelvis can provide detailed images of the kidneys, ureters, and bladder. It is particularly useful for identifying stones, tumors, or other abnormalities that may not be visible on ultrasound or X-ray.

2. Cystoscopy: This procedure involves inserting a thin tube with a camera into the bladder through the urethra. It allows direct visualization of the bladder lining and can help identify tumors, stones, or other abnormalities. Given your concerns about bladder cancer, this is a critical step in ruling out malignancy.

3. Urine Cytology: This test examines urine samples for cancerous cells and can be helpful in detecting bladder cancer.

4. Follow-Up with a Urologist: Given your symptoms and the complexity of your case, consulting a urologist is essential. They can guide you through the necessary tests and interpret the results in the context of your overall health.

Addressing Your Concerns
- Pain and Symptoms: The acute pain you experienced in your left flank and groin could indeed be related to kidney stones, especially if they are moving or causing obstruction. However, the absence of severe pain or other urinary symptoms (like burning or urgency) does not rule out serious conditions.

- Hydration: While increasing fluid intake is generally beneficial, especially for preventing stone formation, it may not resolve the underlying issue if there is a significant pathology present.

- Duration of Symptoms: It is not uncommon for stones to cause intermittent symptoms, but persistent hematuria lasting two months warrants further investigation to rule out more serious conditions, including malignancies.

In conclusion, while there are several potential causes for your intermittent hematuria, the best course of action is to pursue further diagnostic testing, particularly a CT scan and cystoscopy, to ensure a comprehensive evaluation. Early detection and intervention are crucial, especially if there is a risk of malignancy. Please consult with your healthcare provider to discuss these options and ensure you receive the appropriate care.

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