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Blood in Urine - Do You Need a Specialist?

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It could be cancer, kidney stones, urinary tract infection, or even a false positive lab test. Your primary care physician can handle many cases of blood in the urine. In some cases you'll need to see a urologist for an evaluation. In other cases, doctors at the Cleveland Clinic recommend that you see a nephrologist.

Blood in the urine may be obviously visible. This is called gross or macroscopic hematuria, and calls for an evaluation by a urologist in most cases. It may be just a urinary tract infection that can be treated easily with antibiotics, or it may be cancer somewhere in the urinary system. Urologic cancers typically produce intermittent bleeding, so doctors caution against this scenario: Patient goes to primary care physician with bladder pain and blood in the urine. Physician diagnoses urinary tract infection and prescribes antibiotics. The pain and bleeding clear up; both patient and doctor consider the treatment successful. But the patient actually has cancer, which continues to grow until symptoms return. To prevent this mistake, the authors of Reference 1 recommend always doing a urine culture before prescribing an antibiotic for patients with blood in the urine.

At the other end of the risk spectrum, these authors encourage primary care physicians not to refer patients to a urologist if the only sign of blood in the urine is a positive dipstick test. Microhematuria means small amounts of blood in the urine, visible only with microscopic examination of a properly prepared urine specimen. The dipstick test is a simple, low-cost test for microhematuria. Unfortunately, this test is not very accurate. Up to 75% of the patients referred to their urology clinic with microhematuria are found to have nothing wrong. To prevent this mistake, Dr. Rao and Dr. Jones recommend doing the slightly more expensive microscopy test for blood in the urine before sending the patient to a urologist. A Medicare level-4 urological consultation for hematuria costs $170, and exposes the patient to invasive procedures that have their own health risks.

An evaluation by a nephrologist is appropriate if the patient has these lab results:
1. A positive dipstick hematuria test
2. Significant protein in the urine
3. Dysmorphic (abnormally shaped) blood cells in the urine
4. Elevated creatinine in the blood

Early detection and treatment are important for any disease.

by Linda Fugate, Ph.D.


1. Rao PK, Jones JS, “How to evaluate 'dipstick hematuria': What to do before you refer”, Cleveland Clinic Journal of Medicine, March 2008; 75(3): 227-233.

2. See also

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Expert HERWriter Guide Blogger

Hi Linda - The bottom line is - don't ignore blood in urine. Thanks for providing this broad and helpful look at why we need to see our health care provider.
Take good care,

October 30, 2009 - 6:17pm
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We value and respect our HERWriters' experiences, but everyone is different. Many of our writers are speaking from personal experience, and what's worked for them may not work for you. Their articles are not a substitute for medical advice, although we hope you can gain knowledge from their insight.

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