Haematuria History

Differentials

Checklist

Explanation

Preparation

Wash, name, explain:

• Wash your hands
• Introduce yourself by name and role
• Check the patient’s name and date of birth
• Explain the task and get consent

“I have been asked to speak to you today about the blood you have noticed in your urine. I will ask you some questions to try to determine what might be causing the problem. Does that sound all right?”

Presenting Complaint

Begin with an open question to establish the patient’s reason for presenting, for example: “Could you tell me about what’s been going on?”

Try to let the patient speak for 30-60 seconds without interrupting them. This is referred to as the ‘golden minute’ and can offer valuable information about why the patient has sought medical attention, as well as cues surrounding their ideas, concerns, and expectations (ICE) to pick up on later in the consultation.

History of Presenting Complaint

Next, you need to gather more specific information about the patient’s presenting complaint in order to establish the differential diagnosis. You can use a mixture of open and closed questions. 

Examples of open questions here would be: “Could you describe the way your urine looked?” or “Have you noticed any other symptoms alongside the blood?” Examples of closed questions include: “Does it hurt when you pass urine?” or “Have you lost any weight?”

When taking a history of haematuria, it may be useful to think about the following structure for your questions, as well as what useful information the patient’s answers provide about the likely diagnosis:

• Onset – when did the patient first notice blood in the urine? What else was happening at the time? Acute onset haematuria occurring just after urinary catheter insertion may lead you to suspect transient urethral trauma, which should settle, whereas insidious onset haematuria with no clear cause at onset is more concerning for sinister pathology e.g., malignancy.
• Character – ask the patient to describe the way their urine looks. What colour is it? Blood in the urine can appear pink, red, or brown. Has the patient passed any blood clots? Clots may make patients more prone to developing urinary retention.
• Frequency – how often is haematuria happening? Was this a one-off episode, or is it happening every time the patient passes urine? 
• Associated symptoms – has the patient experienced any other symptoms of note? Specific symptoms of interest are discussed below, but an open question early in the history can aid information gathering.
• Recent triggers – triggers for haematuria include trauma or instrumentation to the urinary tract e.g., urinary catheter insertion or prostate biopsy, as well as urinary tract infections and prolonged strenuous exercise e.g., running an ultra-marathon.

System-specific History

After obtaining further details of the presenting complaint, you need to gather any relevant system-specific information. In the case of the presenting complaint of haematuria, the relevant system is the urological system. 

It is important not only to ask about symptoms but also to consider why their presence or absence is significant in narrowing the differential diagnosis. 

Symptoms to enquire about include, but are not limited to:

• Pain – possibly the most important symptom to ask about, as painless haematuria is a red flag for malignancy and should be urgently investigated. Haematuria may be associated with loin to groin or flank pain in kidney stones and pyelonephritis, and with dysuria or suprapubic pain in lower urinary tract infection.
• Lower urinary tract symptoms (LUTS) – haematuria may be associated with urinary frequency and urgency in lower urinary tract infections, whereas voiding symptoms including nocturia, hesitancy, poor urinary flow or terminal dribbling with haematuria may raise suspicion of prostate malignancy.
• Fever – pyrexia with haematuria indicates an infective cause including pyelonephritis, lower urinary tract infection, or even urosepsis if there is significant systemic upset.
• Urine output – reduced urine output (oliguria) associated with infection (pyelonephritis or lower urinary tract infection) is a concerning feature for significant systemic upset and dehydration. Passing blood clots in the urine can lead to urinary retention (clot retention) or blockage of urinary catheters. 

Red Flags

It is important to ask about symptoms that may lead you to consider more sinister causes of haematuria in the differential diagnosis, which may require urgent investigation and management (e.g., to rule out malignancy).

You may need to use closed questions to rule out these symptoms. Patients may not always volunteer this information, as they might find the symptoms worrying or may not have the same insight into their significance as you do. 

Red flag symptoms to screen for when taking a haematuria history include:

• Painless haematuria
• Unintentional weight loss
• Back pain – especially pain that is new, severe, thoracic, or wakes the patient from sleep at night.
• Acute urinary retention – a medical emergency, patients should be advised to attend secondary care for urgent review.

Relevant Systems Review

A systems review is a useful tool to ensure no key information from the history has been missed. However, it is important to consider which systems are relevant to review so that your questions remain pertinent to the presenting complaint.

Relevant systems to review when taking a history of haematuria include the following:

• Renal – glomerular inflammation causing glomerulonephritis may cause haematuria. Other symptoms associated with glomerulonephritis include oedema and oliguria, and proteinuria may be present on dipstick testing.
• Haematological – patients may have other bleeding symptoms e.g., bruising, bleeding gums, nosebleeds or menorrhagia if a coagulopathy is present.

Ideas, Concerns & Expectations (ICE)

Using the ICE mnemonic, you can gather information about how the patient feels about their symptoms, whether they have a specific worry or concern, and how they hope to move forward after seeking medical attention. Try to find your own style of asking about ICE that works for you. Some examples are included below:

• Ideas – “Do you have any thoughts about what might be going on?” “What do you think might be causing this bleeding?”
• Concerns – “Is there anything that is worrying you about the blood in your urine?” “Have you read or Googled anything about finding blood in the urine that has made you anxious?”
• Expectations – “Was there anything specific you were hoping we’d do today?” “Do you have any ideas of what might happen next?”

Past Medical History

Gather information about previous or existing health conditions that the patient may have. Try to note whether an existing condition may be of significance in the context of the presenting complaint of haematuria. 

For example, patients with diabetes or those who are otherwise immunocompromised, as well as those with underlying structural urological abnormalities, are more at risk of developing urinary tract infections and pyelonephritis. There is an association with end-stage CKD and renal cell carcinoma.

Has the patient recently undergone a surgical procedure or instrumentation of the urinary tract e.g., prostate biopsy or cystoscopy, which may account for acute onset haematuria?

Drug History

Ask the patient about any regular medication they take, not forgetting to ask specifically about medications they may not think to volunteer (e.g., over-the-counter medications, herbal or alternative remedies, contraception, HRT, or injections such as B12). Check whether the patient is compliant with their medication and taking it as prescribed.

Consider whether the information you are given could be relevant to the differential diagnosis. For example, consider a patient who presents with haematuria and has recently started anticoagulation e.g., apixaban for atrial fibrillation. 

Remember to ask about drug allergies and clarify any reported symptoms to differentiate a true allergy from an intolerance.

Social History

This is the chance to learn a bit more about the patient, beyond their presenting complaint. Consider asking the following:

• Who do they live with? Do they have a social support network they could depend on if they were to receive a life-changing or life-limiting diagnosis, e.g., malignancy? 
• Do they work? Is their employment history significant? Will the patient require time off work to attend appointments, investigations, or treatment? Do they have a history of working with aromatic amines, a known risk factor for bladder cancer?
• Do they drive? Does their condition affect their ability to drive? Are they able to travel to attend appointments?
• Do they smoke? Smoking is associated with increased risk of malignancy, including bladder and renal cell cancer.
• Do they drink alcohol?
• Do they use recreational drugs? There is an association between anabolic steroid use and increased risk of prostate cancer

Family History

Does anyone in the family have any urological conditions? Patients with a family history of prostate cancer are at increased risk of going on to develop the condition themselves. The commonest form of polycystic kidney disease is inherited in an autosomal dominant pattern.

Do any other health conditions run in the family?

Finishing

Thank the patient and wash your hands. Consider your differential diagnosis and how you might narrow this down further through examination, bedside tests, or further investigation and imaging.

Last updated June 2025

Head to members.zerotofinals.com for practice OSCE stations, including an interactive checklist, specific cases and clinical findings.

✅ How to Learn Medicine Course

✅ Digital Flashcards

✅ Anki-like Fact Trainer

✅ Short Answer Questions

✅ Multiple Choice Questions

✅ Extended Matching Questions

✅ Revision Tracking Tool

✅ OSCE Practice Tool