It is one of the most alarming things you can see in a bathroom, and one of the easiest to talk yourself out of. Blood in the urine, known medically as haematuria, tends to arrive without warning, without pain and without explanation. Then it stops. The water runs clear the next morning, life gets busy, and the episode quietly slides down the list of things worth ringing the surgery about.
That decision to wait and see is why haematuria deserves a conversation of its own. In most cases the cause turns out to be manageable. But blood in the urine is also the most common first sign of bladder cancer, and unlike breast, bowel and cervical cancer, there is no national screening programme to catch it. The symptom is the screening.
TL;DR
- Blood in your urine always needs investigating, even if it happens once and clears on its own. Stopping does not mean resolved.
- Around 20% of people with visible blood in the urine are found to have a urological cancer, and 3 to 5% of those with non-visible blood on a dipstick.
- About 500 people are diagnosed with bladder cancer in Ireland each year, over three quarters aged 65 or older. Smoking is the biggest modifiable risk factor.
- Being on warfarin, a DOAC or aspirin does not explain it away. Blood thinners reveal a problem rather than cause it.
- Ireland has rapid access haematuria pathways, developed from 2019 by the RCSI with the National Clinical Programmes in Urology and Radiology.
Visible and non-visible: two different conversations
Visible haematuria is what you can see: urine turned pink, red, or the colour of strong tea. Sometimes there are small clots. It is usually painless, which is precisely what catches people off guard, because we assume anything serious will hurt.
Non-visible haematuria is blood detected only on a dipstick or laboratory test, often picked up incidentally during a chronic disease review. You would never know it was there. It carries a lower risk than visible bleeding, but in adults over 50 it still warrants a proper look.
A few harmless imposters are worth knowing. Beetroot, blackberries and rhubarb can tint urine pink, and rifampicin, senna-based laxatives and nitrofurantoin can all darken it. If you are unsure, ask your GP or pharmacist rather than dismissing it.
What usually causes it
Most haematuria has a benign explanation. Urinary tract infections are the most common cause, and in older adults they often present without the classic burning or urgency. Kidney and bladder stones can cause bleeding, usually alongside severe loin pain. In men, an enlarged prostate is a frequent culprit. Kidney conditions, recent catheterisation and even a very hard cycling session can all produce blood in the urine.
The less common but more serious causes are cancers of the bladder, kidney, ureter and prostate. Bladder cancer is the most likely of these in someone over 50 with painless visible bleeding. Found early, while still confined to the bladder lining, it is very treatable. The difficulty is that early bladder cancer produces no symptom other than bleeding, and the bleeding comes and goes.
The traps that delay diagnosis
Three assumptions do the most damage.
“It stopped, so it must have been nothing.” Bladder tumours bleed on and off, and a gap of weeks or months between episodes is typical. One episode is enough to warrant investigation, even if everything looks normal by the time you get an appointment.
“It was just a water infection.” Sometimes it genuinely was. But if the blood persists after the antibiotics finish, or the infection keeps returning, that needs following up rather than another prescription. Ask your GP to repeat the urine test after treatment.
“I am on blood thinners, that is why.” This one is common and it is wrong. People on anticoagulants who develop haematuria have the same or higher rates of underlying urological disease as everyone else. Anticoagulation unmasks bleeding that already had a source. Being on warfarin, apixaban, rivaroxaban or aspirin is not a reason to skip the workup. It is a reason to get on with it.
What happens when you go to your GP
Your GP will take a history covering urinary symptoms, smoking, occupational chemical exposure, previous pelvic radiotherapy and family history. Expect a urine sample for dipstick and culture, and bloods for kidney function, full blood count and clotting. Men are usually offered a PSA test as part of the picture.
From there, visible haematuria in an adult over 50, once infection has been excluded, should trigger a referral for specialist assessment. Ireland’s rapid access haematuria pathways, developed from 2019 through a partnership between the Royal College of Surgeons in Ireland and the National Clinical Programmes in Urology and Radiology, exist to shorten that wait. Beaumont Hospital’s service illustrates the demand: new referrals rose from 161 in its first year to 483 in 2023. Availability is not uniform nationally, so it is fair to ask your GP whether a rapid access pathway is available locally and how the referral is being made.
The tests, and what they actually involve
Ultrasound of the kidneys and bladder is painless, involves no radiation, and is often the first imaging step. A CT urogram uses contrast dye to map the kidneys, ureters and bladder in detail, and needs reasonable kidney function, which is one reason for the blood tests beforehand. Irish radiology operates under the 2018 medical exposure regulations overseen by HIQA, so every scan has to be clinically justified.
Flexible cystoscopy is the gold standard for examining the bladder lining, and the one people dread. In practice it is a slim, bendable camera passed through the urethra after local anaesthetic gel, done as an outpatient in five to ten minutes. Most people describe it as undignified rather than genuinely painful, and you go home the same day. Expect some stinging when passing urine for a day or two afterwards, and drink plenty of fluids.
When it is an emergency
Go to an emergency department or ring 112 or 999 if you cannot pass urine at all, if you are passing large clots, if there is heavy bleeding with dizziness or a racing heart, or if blood in your urine comes with a high temperature, shivering, loin pain or confusion, which can signal an infected obstructed kidney and sepsis.
Reducing your risk
Smoking is responsible for roughly two thirds of bladder cancers in men and one third in women, because the chemicals concentrate in urine and sit against the bladder lining. Risk falls after stopping, at any age. The HSE Quitline (1800 201 203) offers free support and free nicotine replacement therapy through Stop Smoking Advisers. Staying well hydrated dilutes the bladder’s exposure. If you worked in painting, printing, hairdressing, textiles, rubber or metalwork in earlier decades, mention it to your GP, since the gap between exposure and disease can run to thirty years.
The one thing worth remembering
You do not need to work out what caused it. Your job is simply to report it, once, to someone who can order a urine test. Most people who do so will get a benign explanation and considerable peace of mind. A small number will get an early diagnosis that changes their outcome entirely.
At Críonna Health we believe ageing well is built on knowing which signals to act on and which to let go. This one belongs firmly in the act-on column. Ring your GP, bring a sample, and let them do the ruling out.
This article is for general information and does not replace individual medical advice. If you have blood in your urine, contact your GP.
📷 Photo by Vitaly Gariev on Unsplash
