Urine samples in a lab

You may have noticed blood in your urine or completed a urine test at a doctor’s office that detected higher than average number of red blood cells in the urine on microscopic analysis of your urine specimen. In either case, you may be wondering if it could be a serious problem and what happens next.

Herbert Ruckle, MD, FACS, chair of Loma Linda University Health’s Urology Department, answers your top questions about hematuria — blood in the urine — and what to expect after reporting seeing blood in your urine or receiving urinalysis test results.

Hematuria (visible or seen only under the microscope) could be an early sign of bladder cancer, Ruckle says, and Bladder Cancer Awareness Month presents a timely opportunity to brush up on your awareness of the disease’s detection and treatment.

What is hematuria, and how does urinalysis testing work?

There are two types of hematuria:

  • gross hematuria: visible blood in the urine
  • microscopic hematuria: blood in the urine visible only via microscope

If you have seen blood in your urine, or gross hematuria, Ruckle advises to visit your doctor as soon as possible and discuss the issue with them — even if it goes away.

"If there's any question that you had blood in your urine, you need to be proactive," Ruckle says. “Do not make assumptions just because symptoms ( hematuria goes?) go away or you hear it's okay because the urine has cleared.”

Your doctor will request a test of your urine, called a urinalysis, that will provide more information on what is happening in your body. Even if you have not seen any blood in your urine, a urinalysis can be administered during a general checkup and picks up on microscopic hematuria.

Hematuria is usually caused by benign (non-cancer) problems — such as urinary tract infections, kidney disease, stones, blood thinners, local trauma — but it also can be the first sign of bladder cancer. There are no official guidelines for bladder cancer screening for the general population, Ruckle says, so it is essential to be aware of the risk factors for bladder cancer, remain vigilant of any changes in your urological health, and complete urinalysis when needed.

A urinalysis’s detection of higher-than-allowed levels of hematuria provides a basis for further investigation, Ruckle says. Hematuria is “elevated” in a urinalysis when there are three or more red blood cells present per high-powered field; a high-powered field indicates the size of the field of view when a microscope reaches its maximum magnification power.

You and your doctor will discuss options for further evaluation after a urinalysis shows elevated hematuria.

My hematuria levels are “elevated” — what could it mean?

First, realize that elevated hematuria does not necessarily mean you have cancer in your bladder, Ruckle says. Other causes of elevated hematuria include but are not limited to:

  • urinary tract infections
  • instrumentation, disruption, or trauma of the urinary tract
  • viral illness, such as hepatitis
  • Conditions like endometriosis, sickle cell disease, kidney disease, or blood-clotting disorders
  • Benign microhematuria — a tendency for the kidneys to leak more blood than usual without posing a danger
  • Exertional microhematuria — rigorous exercise, such as running a marathon
  • Other factors include sexual activity, menstruation, or anti-coagulation medications

You and your doctor will work together to identify any of these possible contributing factors to your higher hematuria and discuss bladder cancer risk factors. Taken together, Ruckle says these factors will inform the type and extent of diagnostic testing you’ll undergo:

  • Renal or kidney ultrasound — The noninvasive diagnostic exam produces images that help physicians assess the kidney's and bladder's size, shape, location, and blood flow. If you are considered low-risk for cancer, you will likely undergo this test.
  • CT scan — You will undergo a CT scan of the abdomen and pelvis outlining the urinary tract, which is usually followed by a cystoscopy if you fall into a slightly higher risk group.
  • MRI — You will undergo an MRI that might be followed by a cystoscopy if you fall in a slightly higher risk group and are allergic to the contrast solution used in CT scans
  • Cystoscopy — The two-minute procedure involves the insertion of a thin, tube-like instrument into the urethra that allows physicians to look inside the bladder with a tiny camera and check for abnormalities. Physicians may also perform a biopsy by collecting tissue samples of the bladder to analyze under a microscope.

If diagnostic test results return negative for cancer, you will proceed with the appropriate treatment or follow-up for the cause or condition behind the elevated hematuria. In addition, Ruckle says you may undergo repeat or routine urinalysis to monitor hematuria levels.

What if my diagnostic results are positive for bladder cancer?

Following a positive result for bladder cancer, the next step is to determine the cancer’s staging — the extent to which cancer has developed by growing and possibly spreading.

Bladder cancer is treatable for most patients through a minimally invasive procedure called an endoscopy, Ruckle says. An endoscopy involves the insertion of a scope into the urethra through which a physician uses tools to cut and remove the tumor from the bladder.

Ruckle says a final step aims to eliminate straggler cancer cells and minimize the chances of the cancer’s return. After the operation, the physician will fill the bladder with chemotherapy and let it sit for an hour. Then it will be drained in the recovery room. In the case of immunotherapy, it can be given intravenously or placed into the bladder.

The most common type of immunotherapy for bladder cancer is BCG (a vaccine previously used against tuberculosis), which is administered intravesically in the clinic a few weeks after the tumor removal procedure. A catheter is inserted into the bladder to drain the urine, the BCG solution is inserted, the catheter is removed, and the patient then holds the solution in the bladder for two hours before urinating it out. Following treatment, you will undergo regular cystoscopy screenings to monitor the bladder.

Surgical bladder removal is an option for the quarter of patients whose bladder cancer has invaded (put roots down) into the organ’s muscle wall at an advanced stage, Ruckle says. Bladder removal surgery (usually performed robotically) may be accompanied by chemotherapy, occasionally radiation treatment, or both. In addition, a subset of these patients may opt for bladder reconstruction surgery that creates a new bladder fashioned from intestine in the body.

Talk with your healthcare provider if you have questions about bladder cancer. To learn more about the variety of resources and support Loma Linda University Cancer Center offers both cancer patients and their loved ones, visit lluh.org/cancer-center or call 800-782-2623.