Blood in a patient's urine can be the result of almost any pathology at any level, but is much more likely to be coming from his bladder than from his upper urinary tact. He can bleed as the result of injury, bacterial infection, parasitic infestation, stones, or neoplasia.

If schistosomiasis is endemic in your district, a patient with frank haematuria, who is over 30, has a 25% chance of having carcinoma of his bladder, so be sure to cystoscope him. Under the age of 30, frank haematuria is much more likely to be due to schistosoma than carcinoma. The other important cause is prostatic hypertrophy. Other causes are rare (renal tuberculosis, carcinoma of the kidney or pelviureteric junction, and vascular abnormalities). Because cystoscopy is so necessary in the diagnosis of malignancy in areas where S. haematobium is endemic, it should be the first investigation after a haemoglobin, a blood urea, a urine microscopy, and (if possible) culture; an intravenous urogram may not be necessary.

Bladder stones seldom cause macroscopic haematuria. Ureteric stones, which are common in much of Asia, but are uncommon in sub-Saharan Africa, usually present with renal colic and microscopic haematuria.

HAEMATURIA Confirm that there really is blood in the patient's urine by examining it microscopically.

THE TWO GLASS TEST. Ask him to pass his urine into two containers, and watch him do it. You may see: (1) A constant ooze from his urethra, indicating a lesion distal to his external sphincter. (2) Initial or terminal haematuria, indicating a local lesion of his bladder or prostate. Terminal haematuria is typical of schistosomiasis. (3) Total haematuria which is equal in both glasses, and may contain worm-like clots, indicates bleeding from his upper urinary tract or bladder; it is common in schistosomiasis and carcinoma of the bladder.

CYSTOSCOPY is usually best done after he stops bleeding. The exceptions are: (1) A bladder full of clot which needs immediate evacuation. (2) Recurrent haematuria when you cannot find a cause, and you would like to know which kidney blood is coming from (rare).