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Hematuria is a word used to refer to blood in the urine.  “Gross” hematuria refers to blood that can 
actually be seen in the urine.  The urine may appear red in color or have a “rusty” or “tea color” to it.  
Microscopic hematuria refers to blood which cannot be seen but which is detected on urinalysis either 
by a chemical dipstick test or by examination of the urine under a microscope.  When hematuria is 
present, the urinary tract requires evaluation.
The urinary tract begins with the  kidneys.  The kidneys, one on each side, sit high in the upper 
abdomen partially underneath the rib cage.  They filter the blood to extract excess waste products and 
fluid to form the urine. Urine, once formed in the kidneys, travels through a tube on each side, the 
ureter, down to the bladder.  Urine is constantly being made by the kidneys and transported through 
the ureters into the bladder.  The bladder stores urine until full and then empties to the outside through 
the urethra.  The urinary system is the same in both men and women from the kidneys to the bladder.  
In men, the urethra is longer and encircled by the prostate which is a gland that is part of the 
reproductive system.
When blood is present in the urine, it is often not a sign of anything which poses a significant threat to 
the health.  As many as 10% of people may have blood in the urine.    One of the most common causes 
for blood in the urine occurs when the kidneys first filter the blood to make the urine.  There may be 
some blood cells which slip through the filter and end up in the urine.  Another common cause of blood 
in the urine in both men and women is mild inflammation which may be present in the lower portion of 
the bladder.  In men, there may be blood in the urine due to benign prostatic hyperplasia, which is the 
normal enlargement of the prostate that occurs in all men beginning at the age of 40.   The primary 
goal of evaluation is to determine if there is underlying abnormality which would put the 
patient’s health at risk. The urinary system is investigated to determine if there may be infection, 
obstruction, scarring, stone or tumor.  
Evaluation for hematuria usually begins with a study of the upper part of the urinary system.  Some 
type of x-ray, known as an imaging study, is carried out to gather information about the kidneys, the 
ureters, and the bladder.  Imaging studies usually include either a  sonogram or a  CT urogram.  A 
sonogram, also known as an ultrasound study, uses sound waves to generate a picture of the kidney.  
The  CT urogram uses x-ray type pictures to give detailed information about the kidneys and the 
ureters.  During the CT urogram, contrast (dye) is injected through one of the veins in the arm or the 
hand.  The dye can then be filtered through the kidneys and the ureter which allows them to show up 
on an x-ray.  CT images are typically taken before and after contrast injection.  Both renal ultrasound 
and CT urogram give limited information about the bladder as well.
The lower part of the urinary tract, the bladder and urethra, is usually studied by cystoscopy.  
Cystoscopy refers to the visual inspection of the bladder and urethra.  This is carried out by inserting a 
small fiberoptic catheter into the urethra and the bladder which  allows direct visualization of these 
structures.  This is typically carried out under a local anesthetic in an examination room in the office.Other tests may be done as well.  A urine culture may be done to check for infection.  Urinary cytology
may help determine if there are any cancerous or pre-cancerous cells that are being shed into the 
urinary system.  Cytology is carried out by doing a “Pap smear” on the voided urine.
In some patients, the above studies may prompt the need for further investigation which can include 
either an MRI study or retrograde pyelogram.  An MRI uses a different type of imaging to give further 
information about the urinary system.  A retrograde pyelogram is a study that can provide more 
detailed information about the ureters.  If the ureters are not seen well or appear abnormal on the CT 
urogram or sonogram, then a retrograde pyelogram may give further details.  A retrograde pyelogram 
study is carried out at the time of cystoscopy by inserting a small catheter into the ureter.    Dye is 
injected through this catheter to demonstrate the ureter.  This is typically carried out in the outpatient 
area of the hospital where the x-ray unit is available to make the necessary pictures.
In most cases, the finding on the CT urogram (or sonogram) and cystoscopy are normal and nothing 
further needs to be done.  If there is an abnormality that is discovered, then it can be treated 
appropriately as indicated.  Again, the main goal of evaluation is to make sure that the blood in the 
urine is not a sign of something which may pose a threat to the patient’s health.  In the case where 
nothing serious is found, symptoms to watch for in the future which may indicate a sign of a problem 
include a change in the urinary pattern to more frequent urination, blood that can be seen in the urine, 
painful urination or pain that originates in the kidney.  Kidney pain typically originates high in the back 
under the ribs and radiates down to the groin area.  If these symptoms develop then repeat evaluation 
may be indicated.
Hematuria is a common problem and with the appropriate workup, the necessary treatment can be 

carried out. 

Protein in the Urine




When considering protein in the urine, it is be helpful to consider how the urinary system works.  The kidneys, one on each side, sit high in the upper abdomen partially underneath the rib cage. They filter the blood to extract excess waste products and fluid to form the urine. Urine, once formed in the kidneys, travels through a tube on each side, the ureter, down to the bladder.  There may be disorder within the kidney, which interferes with the filtering system, which results in protein slipping though the filter to end up in the urine. 


The urinalysis is a study of voided urine.  There are two parts to a urine study – the chemical dipstick and the microscopic examination of the urine.  For the dipstick, a chemical strip with special reagents is dipped into a sample of voided urine.  The reagents are able to assess for a variety of conditions in the urine, including the presence of red bloods cells (blood in the urine, also know as hematuria), protein, sugar, white cells (which can indicate infection) and substances that may indicate impaired liver function.


The microscopic portion of the urine study is carried out by inspecting a sample of urine under the microscope, which can allow the visual identification of red blood cells, white blood cells, bacteria and other elements.


When the dipstick text is positive for protein in the urine, there are several considerations.  Sometimes, protein may be present only on a temporary basis, as can occur in the setting of fever, exercise and stress.  In these cases, the protein may be present in the urine for a short period of time, but will not persist.


When protein is persistently present, and identified on several urinalysis over the course of time, further investigation is warranted.  A 24-hour urine collection is carried out.  All of the urine voided over a 24-hour period is collected, so that the total amount of protein excreted during the 24-hour period can be measured.  The level of creatinine is typically measured also.  Creatinine is a waste product that is cleared in the urine, and the measurement of it offers the opportunity to assess the overall level of kidney function.


In addition to a 24 hour urine collection, an assessment of the anatomic structure of the urinary system may be made with an imaging study, such as an ultrasound or CT scan, which can show if there is anatomical abnormality within the urinary system such as growth, blockage or stone


Blood tests to measure the level of BUN and creatinine may be done, which are another way to assess the overall level of kidney function.


When there is significant protein within the urine, the next step is evaluation by a nephrologist.  Nephrologists are physicians who specialize in evaluation and treatment of the way the kidney functions, and they are different from urologists who are specialists that manage disorders related to the structure of the urinary system (such as growth, blockage or stone) that may require surgical intervention.


A nephrologist can carry out additional tests to determine the reason for impaired kidney function that has caused protein in the urine, and may make appropriate treatment recommendations. 


The table below offers a guide to the correlation between dipstick test and the amount of protein may be present in a 24 hours urine collection.


Dipstick urinalysis

Amount of protein in the urine




30 mg/dL


100 mg/dL


300 mg/dL


1000 mg/dL




The Urology Group, Copyright 2014.  Do not duplicate without permission.

Reference: Blute ML, Vira MA, Peihong H et al: Urinalysis: Proper methods and interpretation. AUA Update Series 2009, Lesson 24, Volume 28.  ©2009 American Urological Association, Education and Research Inc., Linthicum, MD.