Is blood in my urine normal?

Healthy urine is yellow.  The color will change depending on how hydrated you are- clearer urine is more hydrated, and darker urine means that you are more dehydrated.  Urine contains material that your body is excreting or getting rid of.  There can be clues to your health status in the urine.  Back in the day, diabetes was diagnosed when sugar was found in the urine- healthy urine should not contain sugar.  They actually tasted the urine to check it.  That is no longer done (thank goodness), but we have other, less gross ways to test urine.  Healthy urine should also not contain blood.

What happens next when blood is found in my urine?

There are many things that can create blood in the urine.  A strenuous workout can do it.  Bladder infections with certain bacteria cause bloody urine.  A kidney can be the cause.  Menopause can make it more likely to see blood in the urine.  But the thing that we are always worried about is cancer.

When you have blood in the urine, I have to determine how likely you are to have cancer.

There are certain factors that increase your risk.  These factors include:

• How much blood is in the urine
• If you have a history of bloody urine
• Your age
• Your gender
• If you smoke
• If you have had pelvic radiation
• If you have certain genetic factors
• If you have had certain occupational exposures (benzene chemicals and aromatic amines)
• If you have had certain chemotherapies (cyclofosfomide and ifosfomide)
• If you have irritative bladder symptoms like urgency and frequency
• We look at all these factors and then determine if you are low, intermediate, or high risk. What happens next depends on your risk level.

Women at low risk for bladder cancer

Women who are younger than 50 years old have never smoked, have no other risk factors, and have a small amount of microscopic blood in their urine (<3 RBC/hpf) are low risk.  This group can repeat a bladder test (urinalysis) in 6 months or pick to do a cystoscopy or renal ultrasound.  If the bladder test continues to have blood in 6 months, you can opt to do the additional testing then.

Women at intermediate risk for bladder cancer

Women who fall into the intermediate category should have a cystoscopy and renal ultrasound.  This group includes women who are in their 50’s, or who have smoked a moderate amount, or who have a moderate amount of microscopic blood in their urine (11-25 RBC/hpf), or who have another risk factor for bladder cancer.

Women at high risk for bladder cancer

Women who are high risk should have a cystoscopy and CT with contrast.  This group includes women older than 60, women who have smoked for more than 30 years, women who have obviously bloody urine, and women with multiple risk factors.

What does RBC/hpf mean?

Most of the time, women have microscopic blood in their urine.  You can only see it under a microscope.  To evaluate the amount of blood, we actually send the urine to the lab, and someone counts the number of red blood cells (RBCs) that can be seen in a high-power field (hpf) with the microscope.  It is how we know exactly how much blood is there.

What is a cystoscopy?

A cystoscopy is when we take a small camera and look into the bladder.  This lets me see if there is anything in the bladder that could cause the bleeding.  It might be an ulcer, a stone, or even cancer.  Or it might also be a stitch or a piece of mesh from a previous pelvic surgery like a hysterectomy or pelvic floor reconstruction.  Cystoscopies are typically done in the office but can also be done in the operating room. (read more about cystoscopy here https://thewomensbladderdoctor.com/whats-a-cystoscopy/ ) Bladder tumors are often very small and easy to miss with imaging.  This is why the cystoscopy must be done as a CT scan or ultrasound.

What is a CT scan?

A CT scan uses a series of x-rays and computer technology to make a picture of the inside of the body.  It lets me see the whole urinary tract.- Urine is filtered through the kidneys.  It then travels from the kidneys through the ureters to the bladder.  Then it exits the bladder through the urethra.  Imaging lets me look at these structures to see if there is anything abnormal that might be causing the bleeding.  A CT exam with contrast provides the best picture.  It also has some radiation exposure.

What is a renal ultrasound?

An ultrasound can also be done to minimize the radiation associated with a CT scan.  Ultrasounds use sound wave technology to create a picture of the inside of the body.

Is there follow-up?

If your evaluation is negative, we often repeat a urinalysis in a year to make sure you don’t have more blood in your urine.  This can be a sign that something is progressing and getting bigger.  This would result in a second evaluation.

What can cause blood in the urine?

I always worry that the blood means that there is cancer.  This is actually the least common reason but is the most serious.  In women, blood in the urine can be because of a urinary tract infection.  If this is the case, the blood should go away after treating the infection.  It is always a good idea to check this.

Lack of estrogen

A lack of estrogen in the genital tissues can cause there to be a microscopic amount of blood in the urine.  This is part of a syndrome called Genitourinary Syndrome of Menopause, which happens during menopause, so we see this generally in women who are older than 50 years.  It is treated with vaginal estrogen.  Vaginal estrogen is a local treatment, meaning it stays in the vagina and genital area and does not get into the rest of your system.  Studies have shown that blood levels of estrogen stay at the menopausal level when taking vaginal estrogen.  This is a safe and effective treatment.  Again, it always makes to recheck the urine for blood after treatment to ensure it has resolved.

Bladder stones

Bladder stones can cause blood.  These stones are not usually painful because they don’t block the flow of urine.  But they can cause tissue irritation and bleeding.  Kidney stones can also cause bleeding and are usually quite painful.  Treating the stone depends on the size, where it is, and your symptoms, but they are often removed.

Bladder tumors

Bladder tumors always need to be evaluated and treated immediately.

I see a lot of women with blood in their urine and spend a lot of time making sure they don’t have bladder cancers.  Most often, they are fine and need no other treatment.  But I find a tumor a few times a year.  The blood in the urine is a great warning signal- be sure to pay attention to it.  Don’t ignore it and assume it is nothing- take the time to prove it is nothing!  You can find more information about the evaluation of blood in the urine here https://www.auajournals.org/doi/10.1097/JU.0000000000001297

Baracos DA J Urol 2020.