Blood in the urine, recurrent infections and leaking urine

Four symptoms, one path

This page is about symptoms that come from the urinary tract and that many people are embarrassed to mention: blood in the urine, burning and infections that return, and leaking urine. All of them can be assessed and most can be treated. We have written each section separately so you can go straight to the one that is yours.

Blood in the urine

The NHS describes the colour as light pink, red or dark brown, and says that even if the amount is small or you are not sure it is blood, it should be checked. The blood can come from the bladder, kidney or urethra. Possible causes: a urinary infection (burning when you urinate, frequency, smelly or cloudy urine, fever or flank pain), a kidney stone (severe, coming-and-going pain in the flank, back or groin), and an enlarged prostate in men over 50 (difficulty urinating, night-time urination). Sometimes it is not blood at all: beetroot or some medicines change the colour of urine, and bleeding from the rectum or a period can be mistaken for it.

The NHS says blood in the urine can be a sign of cancer and, if found early, it is easier to treat. On its bladder cancer page the NHS also writes that blood in the urine is the main sign and should be checked promptly even if there is no other symptom or if it happened only once and was slight. The point is not to frighten you: the common causes, infection, stones and an enlarged prostate, are treatable, but the only way to know the cause is to have it assessed.

For a small amount of blood that cannot be seen with the eye and is found only under the microscope (microhematuria), the AUA/SUFU guideline sets the threshold at three or more red blood cells per microscope field. The same guideline divides patients into low, intermediate and high risk groups based on age, sex, smoking and other risk factors for urinary tract cancer, and says cystoscopy and imaging of the upper urinary tract should be chosen on that risk and by shared decision. If a gynaecological or non-cancer cause is found, the urine test is repeated after it has resolved. More is in the article Blood in the urine.

If you have clots and cannot pass urine, or the blood comes with fever, chills and severe pain, go to urgent signs.

Burning and infection

The NHS describes the signs of a bladder infection like this: burning or pain when you urinate, frequent and urgent urination or waking at night, cloudy or bloody urine, and pain in the lower abdomen. The signs of a kidney infection differ: back pain just under the ribs, fever or chills with feeling hot and cold, and feeling unwell. The NHS says a kidney infection can lead to sepsis, so do not leave back or flank pain with fever or chills until tomorrow; go to an emergency department at once.

The NHS says that if you have signs of a urinary infection and you are a man, you should get an urgent appointment with a doctor. The other groups on the same list: people over 65, those with diabetes, weakened defences, a urinary catheter, and pregnancy. The same applies to a very high or very low temperature, chills, symptoms getting worse quickly, or blood in the urine. If you are confused or drowsy, or speaking has become difficult, call 115 (Iran’s emergency number), or your local emergency number if you are outside Iran, and do not drive yourself.

When infections keep coming back

The EAU defines recurrent bladder infection as at least three episodes in a year or two episodes in six months, and the NHS also treats three in twelve months or two in six months as a reason to see a doctor. The EAU says the first diagnosis should be confirmed with a urine culture. For a woman under 40 with no risk factors, extensive investigation (cystoscopy, imaging) is usually not needed because the yield is low. But if a stone, blockage of the outflow, interstitial cystitis or cancer is suspected, a prompt work-up is done. The NHS writes that kidney stones and incomplete bladder emptying (for example with an enlarged prostate) are among the causes that raise infection risk. The EAU considers it necessary to rule out a stone if urea-splitting bacteria keep growing.

Prevention, according to the EAU, goes in steps: first counselling and removing risk factors, then non-antibiotic measures, and then preventive antibiotics. On behaviour, the EAU says to avoid drinking too little, deliberately holding urine, not urinating after intercourse, and wiping from back to front, but confirms that the evidence for these tips is limited. In one open trial, drinking an extra 1.5 litres of fluid a day, in premenopausal women who drank less than 1.5 litres, reduced the number of infections and antibiotic use; the EAU rates this recommendation as weak. On cranberry products and D-mannose, the EAU and NHS both say the evidence is limited and mixed: they may help some people but there is no guarantee. If you take warfarin, the NHS says to avoid cranberry, and to ask first in pregnancy.

One important point: bacteria in the urine with no symptoms at all (asymptomatic bacteriuria) is not an infection, and the EAU says it should not be screened for or treated in most people. The exceptions are before urological procedures that damage the lining (EAU, strong recommendation) and in pregnancy. That is why you should have a urine test only if you have symptoms or if your doctor asks. The correct sample is described in the test preparation guide.

Leaking urine (incontinence)

The NHS says urinary incontinence is common, is not an inevitable part of ageing, and a doctor can help. The types:

• Stress: leaks with a cough, a laugh or abdominal pressure, because the pelvic floor muscles and the muscles that close the urethra are weak or damaged.
• Urge: a sudden, strong need to urinate arrives and leaking happens before or at that moment, because the bladder muscle is overactive.
• Overflow: the bladder does not empty completely and leaks little by little all the time. The NHS says the cause is a blockage. In men an enlarged prostate is one possible cause.
• Total and mixed: no storage of urine, or a combination of stress and urge.

For a start, the NHS lists: losing extra weight, cutting down on caffeine and alcohol, pelvic floor exercises, bladder training (gradually lengthen the gap between feeling the need and going), and pads or urine-collecting devices. If these are not enough, medicines are considered and, for some types, surgery (for example a tape under the urethra for stress incontinence). On the bladder diary, the NHS says you may be asked to record your fluid intake and how often you urinate; the EAU also finds a diary of at least three days useful, especially for night-time urination.

Which type of leak you have and which treatment suits you is found out by an examination and a urine test.

A reminder

This page is for general information and does not replace an examination and tests. If you develop a new symptom or your symptoms get worse, come back to be seen.