Blood in the Urine (Hematuria): What It Can Mean and What Happens Next

What it can mean

Blood in the urine is called hematuria. It can be visible (pink, red or cola-colored urine, sometimes with clots) or microscopic (found only on a urine test). The same list of causes applies to both, but visible blood is more likely to have a cause that needs treatment, which is why it should always be checked.

Common and usually benign

Urinary tract infection: Bladder or kidney infections are among the most common causes, often with burning, urgency or frequent urination. Blood usually clears once the infection is treated, and your care team may repeat the test to make sure.
Kidney or bladder stones: Stones can scrape the lining of the urinary tract and cause bleeding, with or without pain in the side, back or groin.
Enlarged prostate: In men, an enlarged prostate (benign prostatic hyperplasia, or BPH) has fragile surface vessels that may bleed, especially with straining.
Recent exercise, injury or a procedure: Strenuous exercise, a blow to the side or back, a recent catheter, cystoscopy or prostate biopsy can all cause temporary bleeding.
Things that look like blood but are not: Menstrual blood mixing with a urine sample, beets, some food dyes and certain medicines can color urine red or orange. A urine test can tell the difference.

Less common

Kidney conditions: Inflammation of the kidney's filters (glomerular disease) can cause blood and protein in the urine, sometimes with high blood pressure or swelling. This is usually evaluated with a nephrologist.
Radiation or medication effects: Past pelvic radiation and some medicines can irritate the bladder lining and cause bleeding years later.
Blood thinners: Anticoagulant and antiplatelet medicines can make bleeding easier, but they rarely cause it on their own. Specialists generally recommend the same evaluation whether or not you take them.

What the work-up checks for

Bladder cancer: Painless visible blood in the urine is the most common first sign of bladder cancer. Cystoscopy, a look inside the bladder, is the test that finds it.
Kidney cancer: Most kidney cancers are now found on scans done for other reasons, but some first appear as blood in the urine. Imaging of the kidneys looks for this.
Cancer of the upper urinary tract: Less often, urothelial cancer starts in the lining of the kidney's drainage system or the ureter. CT urography is designed to show these areas.
Prostate cancer: Prostate cancer rarely causes blood in the urine, but it may be considered in men as part of the overall picture.

Your chance of a serious cause depends on things like age, smoking history, whether the blood was visible, and past exposure to certain chemicals or pelvic radiation. Your care team uses these factors to decide how extensive the evaluation should be. A normal work-up is the most common result.

The usual work-up

What usually happens next

01Confirm the blood and check for infectionA urinalysis with microscopy confirms that red blood cells are present, and a urine culture checks for infection. If an infection is found, it is usually treated first and the urine retested afterward.
02Review your history and blood workYour care team will ask about smoking, medications, work exposures, recent exercise or procedures, and family history. A blood test checks kidney function, which also matters if contrast dye is needed for a scan.
03Imaging of the kidneys and uretersDepending on your risk and the type of bleeding, this may be a kidney ultrasound or a tomography (CT) urogram, a scan with contrast that shows the kidneys, the drainage system and the ureters. If CT contrast is not suitable for you, magnetic resonance imaging (MRI) may be used instead.
04CystoscopyA thin, flexible camera is passed through the urethra to look at the lining of the bladder. It is usually done in the office with numbing gel and takes a few minutes. It is the test that reliably finds or rules out a bladder tumor.
05Urine cytology or other urine tests, in some casesA urine sample may be examined under the microscope for abnormal cells, particularly when visible blood or risk factors are present. These tests support cystoscopy but do not replace it.
06Results and a planMost evaluations are normal or find a benign cause. If a tumor is found in the bladder, the next step is usually a transurethral resection (TURBT) to remove it and learn its type and depth. If the work-up is normal, your care team may suggest a repeat urine test in the future.

The order and the tests vary from person to person. Your care team may skip steps or add others.

Guidelines say · EAU Non-muscle-invasive Bladder Cancer Guidelines, 2023
Recommends a history focused on urinary symptoms and blood in the urine, and kidney and bladder ultrasound and/or CT urography during the initial work-up of hematuria. Cystoscopy is described as necessary to diagnose bladder cancer, and no urine test currently replaces it.

Do not wait

When to seek care urgently

Most blood in the urine can be evaluated with a scheduled appointment. Seek care the same day, or go to an emergency department, if you have any of the following:

You cannot pass urine, or clots are blocking the flow.
Heavy bleeding with dizziness, fainting, a racing heart or shortness of breath.
Fever, chills or shaking together with pain in your side or back.
Severe pain in your side, back or abdomen that does not settle.
Bleeding after a recent injury, surgery or catheter that is getting worse rather than better.

Bring to your visit

Questions to ask

01Was the blood visible, microscopic, or both, and how much was there?
02Could an infection, a stone or a medicine explain it, and will you retest my urine after treatment?
03Which imaging do you recommend for me, ultrasound or CT urography, and why?
04Do I need a cystoscopy, and where and how is it done?
05Does my smoking history or work exposure change how thorough the evaluation should be?
06If everything is normal, when should my urine be checked again?
07What symptoms should make me call before my next appointment?

Common questions

Frequently asked questions

I saw blood once and it went away. Do I still need to be checked?

Generally, yes. Bleeding from a bladder or kidney tumor often comes and goes, so blood that stops on its own does not rule out a cause that needs attention. Your care team can decide how extensive the evaluation should be.

I take a blood thinner. Isn't that the reason?

Blood thinners can make bleeding more noticeable, but they rarely cause it without an underlying source. Specialists generally recommend the same evaluation for people who take them. Do not stop a blood thinner without talking to the doctor who prescribed it.

Does blood in the urine mean I have cancer?

Usually not. Most evaluations find a benign cause or nothing at all. The tests are done because when cancer is the cause, finding it early may make treatment simpler.

Is a cystoscopy painful?

Most people describe it as uncomfortable rather than painful. In the office it is usually done with a flexible scope and numbing gel, and it typically takes a few minutes. Some burning with urination for a day or so afterward is common.

What is microscopic hematuria?

It means red blood cells were seen on a urine test even though the urine looks normal. It is common and often has no serious cause, but depending on your age and risk factors your care team may recommend imaging, cystoscopy or a repeat test.

Why do I need a CT scan if the problem might be in my bladder?

Blood can come from anywhere in the urinary tract, from the kidneys to the urethra. Cystoscopy shows the bladder well, and imaging shows the kidneys and ureters. Together they cover the whole system.