Dr. Kardi Suteja, SpU

YOU will definitely be surprised and worried if you have blood in your urine. Bloody urine in the medical world is known as hematuria. Urination from the blood can occur only at the beginning of urination (initial hematuria), as long as the urine is entirely blood-red (total hematuria) or at the end of urination (terminal hematuria). There are five important questions that must be answered every time a hematuria occurs. First, is the whole urine red? Second, when is the urination red due to blood, the beginning of urination, the end of urination or from the beginning to the end of urination? Third, is bloody urine accompanied by pain? Fourth, is there a blood clot when urinating? Fifth, what is the form of blood clots released when urinating? For those of you who have bloody urine, the most important thing is, you are able to answer honestly the five questions when you see a doctor. An open honest answer is already very helpful for doctors to make a diagnosis. Furthermore, entrust a medical examination to the doctor.

Symptoms and Location of Bleeding

The time of bloody urine is often related to the location of the bleeding. In the initial hematuria bleeding usually arises from the urethra (urinary tract below the bladder). When there is total hematuria often the origin of bleeding is from the bladder or from the upper urinary tract starting from the kidneys, and ureters. If the bladder neck is bleeding, bloody urine is usually at the end of urination when pushing to pass urine (terminal hematuria)

The presence of blood clots indicates the severity of the degree of hematuria, as a sign of possible more serious abnormalities in the urinary tract. The form of blood clots can indicate the location of the source of the disorder. If the irregular shape is likely blood comes from the bladder or the urethra at the back. Blood clots that are shaped like worms, especially when associated with flank pain, are likely blood clots from the upper urinary tract.

There are two kinds of bloody urine. Bloody urine with no pain (painless hematuria) and with pain. Pain when urinating will arise when associated with inflammation or obstruction. Suffering with a bladder infection accompanied by bloody urine will experience pain due to irritative symptoms. More often the pain accompanied by bloody urine comes from the upper urinary tract, as a result of ureteral obstruction due to stones or blood clots.

Causes of Hematuria

Hematuria can be distinguished into hematuria that is seen roughly by the naked eye (gross hematuria) and hematuria that appears after laboratory examination (microscopic hematuria). Microscopically, if there are more than three red blood cells per large field of view in the urine, this is a significant sign. Very rarely patients with gross hematuria experience no abnormalities in the urinary tract. But the opposite is very often, abnormalities are found in patients with microscopic hematuria.

Hematuria in various degrees should not be underestimated, especially in adults it should be considered as a sign of a malignant tumor until proven not benign. Hematuria is caused by a variety of conditions, usually due to infection, drugs, immunological abnormalities, trauma, stones, tumors or unknown causes (idiopathic). Bloody urine although it looks scary, is usually without pain. However do not get too excited, painless bloody urine should be taken more carefully because often the cause is a from urinary tract tumor.

In summary, the causes of hematuria can be grouped into two. First, hematuria due to abnormalities in kidney tissue, which require no surgery (nephrologic hematuria) and the reverse is hematuria due to the urinary tract problem (surgical hematuria) which does.

The role of X-rays

Physical examination sometimes do not find abnormalities. On laboratory tests, red blood cells can be found in the urine or decreased blood hemoglobin levels. Detecting the presence or absence of tumor cells in the urine cytology examination can be done. These examinations includenplain x-rays of the kidney and bladder (blast nier oversich photo) and IVP (intravenous pyelography) to see the function of excretion and morphology of the upper urinary tract. If there are suspicious X-ray images, CT scan (computerized tomography scanning) often has to be done. Or if you want it to be more sophisticated you can do an MRI (magnetic resonance imaging) examination. The last two imaging checks are done with clear indications because the cost is not cheap.

If not due to an emergency trauma, then the urologist will perform binoculars down to the bladder (cystoscopy). Cystoscopic examination of the bladder can be seen in the presence or absence of abnormalities in the lower urinary tract, tumor, stones, or abnormalities in the bladder.

When viewing the bladder, urine flow can be seen from the two urethral estuaries (the upper urinary tract between the kidneys to the bladder). When the bleeding comes out of the ureteral estuary, urine samples are taken directly from the kidney through the ureter with a sort of urinary tube (ureter catheter). If there is a tumor in the bladder, then a suspicious tissue (biopsy) is taken by a urologist to be sent to an anatomic pathology laboratory to determine the type of tumor.

Overall urologists are doctors who play a central role in handling cases of bloody urine. The therapeutic decision can be either medical (medication) alone, surgery alone or both depending on the cause of hematuria. If the cause is a kidney or bladder tumor the choice of therapy depends on the stage of the tumor. Here the timing of the discovery of that tumor is very important. Earlier the tumor is known the therapy will provide a better prognosis. Maybe in the future with the increasing public awareness of health and screening for tumors in the urinary tract will be something that is not strange and become a necessity of the community. The motto ‘better prevent than cure’ still seems to apply.

Dr. Kardi Suteja, SpU.  specialist doctor of urological surgery at Karsuneka Urology Clinic Denpasar and several private hospitals in Bali.