Intended for healthcare professionals

Practice Rational Imaging

Investigating painless haematuria

BMJ 2008; 337 doi: (Published 09 July 2008) Cite this as: BMJ 2008;337:a260
  1. Sylvia A O’Keeffe, specialist registrar1,
  2. Sorcha McNally, specialist registrar1,
  3. Mary T Keogan, consultant radiologist 1
  1. 1St James’s Hospital, Dublin 8, Ireland
  1. Correspondence to: S A O’Keeffe sylviaokeeffe{at}

    Learning points

    • All patients with painless haematuria need cystoscopy to exclude bladder cancer

    • All patients need imaging of the kidneys, by ultrasound or computed tomography urography, to look for renal cell carcinoma or transitional cell carcinoma of the renal pelvis

    • Patients with persistent haematuria and a normal ultrasound and cystoscopy or those at high risk need intravenous urography or computed tomography urography to increase the chance of detecting transitional cell carcinoma of the ureter

    • Computed tomography urography is replacing ultrasound and intravenous urography where it is available, particularly in high risk patients

    • Computed tomography or ultrasound guided biopsy of renal lesions is becoming the investigation of choice to avoid unnecessary nephrectomy for benign disease

    • Radiofrequency ablation is a treatment option for renal cell carcinoma in patients who are not good candidates for surgery, particularly for tumours smaller than 3 cm

    The patient

    An 81 year old woman was referred by her general practitioner with microscopic haematuria, diagnosed initially on dipstick in the practice surgery on two occasions. She had presented to her general practitioner with frequency. She denied any dysuria, loin pain, macroscopic haematuria, or weight loss. She had undergone a left nephrectomy 20 years before for a limited stage renal cell carcinoma. She was an ex-smoker of 30 pack years (the product of years of smoking and the mean number of cigarettes per day divided by 20) with known chronic obstructive airways disease, angina, and mild renal impairment. Urine microscopy showed 10-50 ×103 leucocytes/ml urine, 10-50 ×103 erythrocytes/ml of urine, no epithelial cells, no bacterial growth, and negative cytology for malignancy.

    What should be the next investigation?

    Several different algorithms have been recommended for investigating painless haematuria.1 2 3 These algorithms were devised by the health technology assessment programme (part of the National Institute for Health Research in the United Kingdom), the Scottish Intercollegiate …

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