Painless Hematuria: Key Questions for Urology Evaluation

Q: Painless Hematuria: Key Questions for Urology Evaluation

Hello, I would like to ask Director Du：<br>1. <br>After only a 10-day interval for a follow-up test, the WBC has turned negative, but there are still 3-5 RBCs. <br>Based on Director Du's experience, could it be that after the urinary tract infection improves, the WBC disappears f

Ask about painless hematuria for mom - 2?

Thank you, Director Du, for your response.
Today, I have updated the urine test data again.

1.
A 65-year-old female patient had a urine test six months ago (May 2021) before undergoing lumbar surgery, which showed an OB (occult blood) result of 2+, while other values were normal (RBC, WBC, etc., all negative).

2.
Recently (November 15, 2021), at a metabolic clinic for monitoring hypertension and thyroid function, a urine test was conducted, which revealed some abnormal results (though my mother reported no symptoms).
The results included:
- 1.
Turbid urine
- 2.
OB: 2+
- 3.
RBC: 10-194
- 4.
WBC: 6-9
- 5.
Leukocyte esterase: 2+
- 6.
Other - Urine: Mucous
The rest were negative.
My mother has been undergoing abdominal ultrasound monitoring for liver cysts, and a 0.3 cm kidney stone has been present for over two years.
She has been taking natto and red yeast rice to manage her slightly elevated cholesterol levels.

3.
After a 10-day interval (November 25, 2021), during which she increased her water intake and did not hold her urine, she went to a major hospital's urology department for a re-examination.
A young doctor stated that there was no sign of inflammation, with only RBC: 3-5 present, and no further tests were necessary, mentioning that this condition is common and often does not reveal significant findings.
The doctor also noted that my mother does not smoke and has no family history of urinary tract tumors, so there is no need for concern.
I would like to ask Director Du:
1.
Given that the follow-up was only 10 days later and the WBC returned to negative while RBC remained at 3-5, based on your experience, could this indicate that the urinary tract infection improved, with WBC disappearing first and RBC gradually decreasing afterward?
2.
If she drinks a lot of water and the urine color appears clearer during the test, would the RBC count also decrease? Can the water intake affect the accuracy of the results?
3.
If we want to pursue further testing, what examinations would you recommend for us to discuss with the physician? What are the typical steps to investigate the underlying cause of painless hematuria?

Mr. Chen, 30~39 year old female. Ask Date: 2021/11/26

Dr. Du Shixi reply Urology

Hello, I would like to ask Director Du:
1.
After only a 10-day interval for a follow-up test, the WBC has turned negative, but there are still 3-5 RBCs.
Based on Director Du's experience, could it be that after the urinary tract infection improves, the WBC disappears first and then the RBCs gradually decrease? --> The RBC count may fluctuate, sometimes more and sometimes less.
If there is no visible hematuria, performing an ultrasound and X-ray is sufficient, but regular urine tests should be conducted, such as every three months.
If there is visible hematuria, immediate medical attention is necessary.
2.
If a person drinks a lot of water, and the urine appears clearer during the urine test, will the RBC count also decrease? (Can the water intake cause the data to be inaccurate?) --> It is possible.
3.
If further examination is desired, what tests does Director Du recommend for us to discuss with our physician? What are the usual steps to investigate the underlying cause of painless hematuria? (If there is visible hematuria, a cystoscopy is required.
If there is no visible hematuria, an ultrasound and X-ray should be performed, and further tests can be determined based on the results.)
Wishing you good health.

Reply Date: 2021/11/26

More Info

Understanding painless hematuria, or the presence of blood in urine without accompanying pain, is crucial for proper urological evaluation. Hematuria can be a symptom of various underlying conditions, some benign and others potentially serious. Here are key questions and considerations that can guide both patients and healthcare providers in evaluating this condition.

Key Questions for Urology Evaluation
1. Duration and Frequency of Hematuria: How long has the hematuria been present? Is it persistent, intermittent, or occasional? Understanding the pattern can help determine the underlying cause.

2. Associated Symptoms: Although the hematuria is painless, are there any other symptoms present? For instance, changes in urinary frequency, urgency, or any signs of infection (such as fever or chills) can provide clues.

3. Medical History: Are there any significant medical conditions, such as a history of kidney stones, urinary tract infections, or systemic diseases like diabetes or hypertension? Additionally, any history of smoking or family history of urinary tract cancers should be noted.

4. Medications and Supplements: Are there any medications or supplements being taken that could contribute to hematuria? Certain anticoagulants, nonsteroidal anti-inflammatory drugs (NSAIDs), and even some herbal supplements can affect bleeding.

5. Recent Procedures: Have there been any recent medical procedures involving the urinary tract, such as catheterization, cystoscopy, or surgery? These can sometimes lead to transient hematuria.

Diagnostic Approach
Given the complexity of painless hematuria, a systematic approach is essential. Here are some recommended steps for further evaluation:
1. Urinalysis: A comprehensive urinalysis is the first step. This includes checking for red blood cells (RBCs), white blood cells (WBCs), protein, and the presence of any bacteria or crystals. The presence of RBCs, as noted in your case, can indicate various conditions, including glomerular disease, urinary tract infections, or malignancy.

2. Urine Culture: If there is any suspicion of infection, a urine culture can help identify bacterial pathogens and guide antibiotic therapy.

3. Imaging Studies: Depending on the findings from urinalysis, imaging studies such as an ultrasound, CT scan, or MRI may be warranted to visualize the kidneys, ureters, and bladder for any structural abnormalities, stones, or tumors.

4. Cystoscopy: If the imaging studies do not reveal a clear cause, a cystoscopy may be performed. This procedure allows direct visualization of the bladder and urethra, which can help identify lesions, tumors, or other abnormalities.

5. Blood Tests: Additional blood tests may be necessary to assess kidney function and check for any systemic conditions that could contribute to hematuria.

Addressing Your Specific Questions
1. RBC Persistence: It is possible for RBCs to remain in the urine even after WBCs have returned to normal, especially if there was a prior infection. Infections can cause inflammation and damage to the urinary tract lining, leading to bleeding that may take time to resolve.

2. Hydration and Urine Clarity: Increased fluid intake can dilute urine, potentially leading to a clearer appearance. However, it is important to note that while hydration can affect the concentration of RBCs, it does not necessarily eliminate the presence of RBCs if there is an underlying issue.

3. Further Testing: If you wish to pursue further evaluation, discussing the possibility of imaging studies or cystoscopy with your urologist would be prudent. These tests can provide more definitive answers regarding the cause of hematuria.

Conclusion
Painless hematuria warrants careful evaluation to rule out serious conditions. While many cases may be benign, it is essential to follow a thorough diagnostic pathway to ensure that any underlying issues are identified and managed appropriately. Regular follow-ups with your healthcare provider are crucial, especially if symptoms persist or worsen.

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