Blood in the urine can be alarming
It’s amazing how the comment from a healthcare provider, “You need further testing” can put us in a tailspin of fear. It may be because we have heard about others’ experiences or read something on the internet.
A few years ago, I had a couple of tests to follow-up on some symptoms of a urinary tract infection. Test results came back negative, but my primary care physician referred me to a urologist for further evaluation because one test showed some red blood cells in my urine.
She told me it was asymptomatic microscopic hematuria (AMH), which sounded intimidating and quite possibly like a major disease, but it’s not. Simply put, it’s a trace amount of red blood cells that can be seen only under a microscope when you have a urinalysis done to check your urine for a urinary tract infection or kidney problem.
The American Urological Association (AUA) defines it as “three or greater red blood cells per high-powered field (HPF) of a properly collected urinary specimen, in the absence of an obvious benign cause.”
The AUA also categorizes it as a “sign, not a diagnosis of a health condition.”
I admit, I was fearful that I might get a cancer diagnosis and wasn’t so sure about the testing I would have to go through. As it turns out, my fears were unfounded.
“AMH is a very common condition that we see quite a bit, almost on a daily basis,” said Evangelos G. Geraniotis MD, FACS, a urologist with Cape Cod Hospital.
Because AMH is a sign, it requires further investigation to find out why it is happening. More than three red blood cells in the urine without an infection can be an indication that something is going on with your kidneys or bladder.
“When you have AMH, we have to evaluate both the upper and lower urinary tract,” explained Dr. Geraniotis. “The upper tract consists of the kidneys and ureters, the lower tract includes the bladder as well as the prostate in men.”
The patient is usually referred to a urologist when their primary care physician has either done a routine urinalysis for an annual physical or because a patient has symptoms and the urine is checked as part of their evaluation, he said.
He said while most patients are over 40, he has seen it in adults in their 20s and 30s, as well as children.
The Investigation and The Causes
To investigate the symptoms, a urologist will do an evaluation of the kidneys with either a CT scan of the abdomen or an ultrasound of the kidneys, said Dr. Geraniotis. The physician will then conduct an evaluation of the bladder with an exam called a cystoscopy, which uses a small camera and telescopic device.
The results of the CT scan and ultrasound tests from my first evaluation were essentially normal. I was then facing a cystoscopy, which made me nervous because I was concerned that it would be painful. But my worries were unfounded, as I did not experience any pain or discomfort during the procedure.
“The Cystoscopy is what people fear the most and it’s the part of the evaluation that keeps many people from coming in to see us, “said Dr. Geraniotis. “Many times, I’ll see a patient who tells me their PCP referred them to me a year ago but put it off because they didn’t want a cystoscopy.”
A topical gel is used to numb the area. Once the gel is applied, the process is seamless and only takes a few minutes.
The most common finding in a cystoscopy is a normal bladder, Dr. Geraniotis explained. While many patients are concerned and fearful they may have cancer, urinary tract malignancies are rare.
“In the overall number of patients we see for AMH, the number of times we find cancer is small,” he said. “We more often find a kidney stone.”
Patients with a negative evaluation are left to wonder about the source of the blood in their urine.
“With negative evaluations, we don’t know exactly where the blood is coming from because we can’t pinpoint a specific location.” said Dr. Geraniotis.
However, one of the theories is that AMH originates inside the kidney tubules where the membrane filters blood. It’s thought that a few red blood cells escape through the filtering system of the kidneys and move into the urinary tract where they pass through the bladder with the urine.
My evaluation was negative both times and I was relieved. Dr. Geraniotis told me I should have a urine test annually and, if after five years I continue to have AMH, he will do another evaluation. However, if anything changes in the meantime, I would need to go back to see him.
“If patients develop gross hematuria (you can see the blood in your urine), and/or protein in a urinalysis, that is cause for concern,” he said. “We would need to do another evaluation regardless of how long ago the AMH was evaluated by us, even if it’s only been a short time.”