Surgery chapters
Bladder stones and haematuria
Primary and secondary bladder stones, their composition, symptoms, investigation and endoscopic or open removal; and haematuria: definitions, timing, causes from kidney to urethra, false red urine, the haematuria clinic work-up and clot retention.
- Primary bladder stones form in sterile urine (historically in poorly nourished children); secondary stones form with outflow obstruction, infection, residual urine or a foreign body; treat the stone and its cause, usually by endoscopic litholapaxy plus TURP if needed.
- Haematuria is visible or non-visible; timing hints at the site (initial = urethra, terminal = bladder neck or prostate, total = bladder or above).
- Painless visible haematuria in an adult means cancer until proven otherwise: work up with urine culture and cytology, renal function, ultrasound or CT urography, and flexible cystoscopy.
On this page
Overview
Bladder stones and haematuria are linked: a stone in the bladder classically causes terminal haematuria, and both are common reasons for cystoscopy.
Haematuria is one of the three commonest urological emergencies. The overriding rule is that unexplained haematuria in an adult must be fully investigated, because it may be the first sign of a urological cancer.
Bladder stones (vesical calculi)
Definitions
| Type | Meaning |
|---|---|
| Primary stone | Forms in sterile urine; often begins in the kidney and drops into the bladder |
| Secondary stone | Forms in the presence of infection, outflow obstruction, poor bladder emptying or a foreign body |
Causes of secondary stones
- Bladder outflow obstruction: BPH, urethral stricture, bladder neck stenosis (the commonest setting in adult men).
- Incomplete emptying: neurogenic bladder, bladder diverticulum.
- Infection with urease-splitting organisms (Proteus).
- Foreign bodies: catheter balloon fragments (commonest foreign body), long-term catheters, non-absorbable sutures, self-inserted objects.
- Augmented bladders and urinary diversions (mucus and stasis).
- Schistosomiasis.
Epidemiology
- Primary bladder stones were once common in poor, malnourished children (low-protein, cereal-based diets). They are still seen in parts of South Asia, including Pakistan, but are rare where diet has improved.
- In adults, bladder stones are mostly secondary. Men are affected about eight times as often as women.
Composition
| Stone | Features |
|---|---|
| Mixed | Most bladder stones |
| Calcium oxalate | Primary; slow growing, usually single, rough or spiky surface; dark brown or black from blood pigment |
| Uric acid | Round or oval, smooth, yellow to brown; gout, ileostomy, outflow obstruction |
| Triple phosphate (struvite) | Ammonium magnesium calcium phosphate; infected urine with urease producers; grows fast; dirty white, chalky; may form on another stone or a foreign body |
| Cystine | Only with cystinuria; radio-opaque (sulphur) |
Stones move freely and settle in the lowest part of the bladder unless trapped in a diverticulum.
Clinical features
- May be asymptomatic and found by chance.
- Frequency is the earliest symptom; a feeling of incomplete emptying.
- Pain (strangury) as voiding finishes, felt at the penile tip or in the labia; worse with movement. Commonest with spiky oxalate stones.
- Terminal haematuria: some drops of fresh bright red blood as voiding ends, because the stone rubs the vascular trigone.
- Interruption of the stream: the stone suddenly blocks the bladder neck; changing posture may let the flow restart.
- UTI is a common presentation.
- In young boys: the child cries and tugs at the penis as he finishes voiding.
Stone in the bladder = "Stop–start, Sting at the end, Spots of blood."
Examination
Usually normal. Rectal or vaginal examination may feel a very large stone in women. Look for a cause: enlarged prostate, palpable bladder, phimosis or meatal stenosis.
Investigations
- Urine: microscopic haematuria, pus cells, crystals (envelope-shaped oxalate, hexagonal cystine), culture.
- Plain X-ray (KUB): most stones are radio-opaque.
- Ultrasound: echogenic focus with an acoustic shadow that moves with position; also residual urine, prostate size and upper tracts.
- Image the whole tract to exclude kidney stones.
- Cystoscopy: confirms the stone and shows the cause (prostate, stricture, diverticulum, tumour).
- Flow rate and residual; U&E.
Management
Treat the stone and remove the cause.
| Method | Details |
|---|---|
| Transurethral cystolitholapaxy (endoscopic) | Stone broken under vision with a mechanical (optical) lithotrite, holmium laser, electrohydraulic or ultrasound probe; fragments washed out with an Ellik evacuator. Nearly all stones can be treated this way |
| Percutaneous suprapubic cystolitholapaxy | Track made into the bladder through the abdominal wall; used when the urethra is too narrow (e.g. small boys) or long |
| Open cystolithotomy (suprapubic) | Very large or very hard stones; when open prostatectomy or diverticulectomy is also needed |
| Treat the cause | TURP at the same sitting for BPH; treat a stricture; CISC for neurogenic bladder; remove foreign bodies; treat infection |
Transurethral litholapaxy may be unsuitable with a stricture that cannot be dilated, in young children (narrow urethra), with a small contracted bladder, or with a very large stone.
Long-standing bladder stones cause chronic irritation and squamous metaplasia, which raises the risk of squamous cell carcinoma of the bladder.
Do not forget the underlying cause. Removing a bladder stone in a man with BPH without relieving the obstruction invites recurrence.
Haematuria
Definitions
| Term | Meaning |
|---|---|
| Visible haematuria (VH) | Blood the patient can see (old terms: macroscopic, gross, frank) |
| Non-visible haematuria (NVH) | Blood found on dipstick or microscopy only (old terms: microscopic, dipstick) |
| Symptomatic NVH | NVH with LUTS such as frequency or dysuria |
| Asymptomatic NVH | NVH found incidentally |
A trace of blood on dipstick is treated as negative. Persistent NVH is usually defined by repeated positive dipsticks.
Timing of bleeding in the stream
| Timing | Likely source |
|---|---|
| Initial (start of stream) | Urethra (anterior urethral lesion) |
| Terminal (end of stream) | Bladder neck, prostate, trigone; bladder stone; schistosomiasis |
| Total (throughout) | Bladder or upper tract (kidney, ureter) |
Worm-like clots suggest bleeding from the upper tract (casts of the ureter).
Causes: think "TIN" at every level
Trauma, Infection and Neoplasm, plus stones and medical causes.
| Site | Causes |
|---|---|
| Kidney | Renal cell carcinoma, urothelial tumour of the pelvis, Wilms tumour (child), stones, trauma, pyelonephritis, TB, glomerulonephritis (IgA nephropathy), ADPKD, papillary necrosis (sickle cell, diabetes, analgesic abuse), renal infarct, renal vein thrombosis, arteriovenous malformation |
| Ureter | Stone, urothelial tumour, trauma |
| Bladder | Urothelial carcinoma (commonest serious cause), cystitis, stone, schistosomiasis, radiation cystitis, cyclophosphamide haemorrhagic cystitis, trauma, endometriosis |
| Prostate | BPH (fragile veins at the bladder base), prostate cancer, prostatitis |
| Urethra | Trauma, stone, urethritis, tumour, stricture |
| General | Anticoagulants, bleeding disorders, sickle cell disease or trait, vigorous exercise |
Red urine without red cells
Dipstick is positive but no red cells are seen on microscopy:
- Haemoglobinuria: intravascular haemolysis (e.g. "march" haemoglobinuria, mismatched transfusion).
- Myoglobinuria: rhabdomyolysis after crush injury.
Dipstick is negative:
- Drugs: rifampicin (orange-red), phenazopyridine, senna.
- Food: beetroot.
- Porphyria (darkens on standing in light).
- Brown urine: nitrofurantoin, metronidazole, conjugated bilirubin in obstructive jaundice.
Red urine with a positive dipstick but no red cells on microscopy is haemoglobinuria or myoglobinuria, not haematuria. Rhabdomyolysis after a crush injury is the classic surgical cause.
Glomerular versus urological bleeding
| Glomerular (medical) | Urological (surgical) |
|---|---|
| Dysmorphic red cells, red cell casts | Normal-shaped red cells, clots |
| Proteinuria, raised creatinine, hypertension | No significant proteinuria |
| Often young, after a sore throat (IgA) | Often older, smoker |
| Refer to nephrology | Refer to urology |
Clinical assessment
- Age and risk factors: smoking, occupational dye or rubber exposure, pelvic radiotherapy, cyclophosphamide, schistosomiasis, stone history.
- Pain: loin-to-groin colic (stone, clot), dysuria (infection), or painless (think tumour).
- LUTS, weight loss, family history (ADPKD).
- Examination: blood pressure, abdominal or loin mass, palpable bladder, DRE, external genitalia, oedema.
Painless visible haematuria in an adult is due to a urological cancer until proven otherwise, most often bladder cancer. The cancer detection rate is about 20% for visible haematuria and under 5% for non-visible haematuria.
Investigations
Except for a young woman with a proven UTI whose bleeding clears with treatment, adults with haematuria should be investigated, ideally in a one-stop haematuria clinic.
- Urine: dipstick, microscopy (red cells, casts), culture, cytology.
- Blood: FBC, U&E/eGFR, clotting if on anticoagulants; PSA if appropriate.
- Upper tract imaging:
- Renal ultrasound at minimum.
- CT urography for visible haematuria and higher-risk patients (shows renal tumours, upper tract urothelial tumours and stones).
- Lower tract: flexible cystoscopy (under local anaesthetic) at minimum.
Haematuria in a patient on warfarin or a DOAC must still be fully investigated. Anticoagulants unmask bleeding from an underlying lesion; they rarely cause it alone.
Management principles
- Treat the cause (tumour resection, stone removal, antibiotics).
- Clot retention: pass a large three-way catheter, wash out clots, then start continuous bladder irrigation with saline; correct clotting; transfuse if needed.
- Bleeding from BPH: 5α-reductase inhibitors (finasteride) or TURP.
- Persistent bleeding from radiation cystitis or inoperable tumour: endoscopic diathermy, intravesical agents, embolisation of internal iliac branches, palliative radiotherapy; rarely cystectomy.
- Glomerular causes: refer to nephrology.
Schistosomiasis of the bladder (Pakistan and travel)
- Schistosoma haematobium adult worms live in the vesical venous plexus; eggs with a terminal spine lodge in the bladder wall.
- Terminal haematuria, frequency, "sandy patches" at cystoscopy, calcified bladder wall on X-ray, ureteric strictures.
- Long-term risk of squamous cell carcinoma.
- Treatment: praziquantel.
Expect: primary versus secondary bladder stones, bladder stones in boys (pulling at the penis), strangury and terminal haematuria, interrupted stream, ultrasound and cystoscopy, litholapaxy with TURP for BPH, catheter balloon fragments as foreign-body nidus, squamous cell carcinoma risk; for haematuria: timing and source, TIN causes, painless visible haematuria meaning bladder cancer, cystoscopy plus CT urography, haemoglobinuria, myoglobinuria and drugs causing red urine, anticoagulated patients still needing work-up, and clot retention.
Quick revision
- Primary stone: sterile urine; secondary: obstruction, infection, stasis, foreign body.
- Men 8:1; frequency first; strangury to penile tip; terminal bright blood; stop–start stream.
- Boys: crying and pulling the penis after voiding.
- Treatment: endoscopic litholapaxy + treat cause (TURP); open for huge stones.
- Haematuria timing: initial urethra, terminal bladder neck/prostate, total bladder or above.
- Painless VH → cystoscopy + CT urography; cancer in ~20% of VH.
- Dipstick positive, no red cells → haemoglobin or myoglobin.
- Rifampicin and beetroot → red urine, dipstick negative.
- Anticoagulated patients still need full investigation.
- Clot retention → three-way catheter, washout, irrigation.
Written by The House Job from standard references (Bailey & Love; Kumar and Clark's Clinical Medicine).
FAQ
What is the difference between a primary and secondary bladder stone?
A primary stone forms in sterile urine, often starting in the kidney. A secondary stone forms because of outflow obstruction, infection, poor emptying or a foreign body, and is the usual type in adults today.
What does terminal haematuria point to?
A source at the bladder neck, trigone or prostate, such as a bladder stone, prostatic bleeding or schistosomiasis.
How should painless visible haematuria be investigated?
With urine culture and cytology, renal function, upper tract imaging (CT urography or at least ultrasound) and cystoscopy, because bladder or kidney cancer must be excluded.
Why can the urine dipstick show blood when microscopy shows no red cells?
The dipstick detects haem, so haemoglobin released by haemolysis or myoglobin from muscle breakdown gives a positive result without red cells.