There will be blood

In 2007, Daniel Day-Lewis starred in an epic movie playing the role of a man driven to seek his wealth in the California oil rush in the early 20th century. The title foreshadows that in seeking oil, and capitalizing on the opportunity, blood will be spilled; this was inevitable. There are places where blood should be – the heart, arteries, veins, and capillaries. And there are places it should not be – spilled on the streets or on oilfields, or in your urine.

I was inspired to write this episode by a panicked telephone call from a dear friend who told me he had passed red urine that morning. Having established that he had not eaten copious amounts of foods that can color the urine red (blackberries, rhubarb, and beetroot), taken the laxative senna, the urinary tract painkiller phenazopyridine, or was not being treated for tuberculosis with the antibiotic rifampicin, the likely candidate was blood in his pee.

Frank blood is not the name of a Hollywood hitman but refers to when blood can be seen clearly and is in contrast to microscopic hematuria, our fancy way of saying that blood is present, but cannot be seen with the naked eye. One element of the AME medical is where they ask for a urine sample and use a diagnostic stick to look for elements that should not be present, like blood or sugar. Causes of either frank or microscopic blood are the same, but sometimes if the initiating issue is chronic, the bleeding may progress over a period of time from mere tinges to a torrent.

First, if you see blood where it shouldn’t be, seek attention; if you saw blood on the streets you would call the police; if you see blood in the bowl see your doctor immediately.

Oil is a precious resource and if it runs out there are consequences: energy production is reduced, transportation will fail, and eventually the lights will go out. Guess what, it is the same if your personal blood supply is depleted; you will lack energy, movement will slow down, and as blood supply to your heart and brain suffers from the resulting anemia (lack of red blood cells and the oxygen-carrying hemoglobin they contain) your lights will go out. Permanently.

General conditions that can cause hematuria are clotting disorders that might result from a host of disease states, or taking medicine like Coumadin for atrial fibrillation (abnormal heart rhythm) or after having a new heart valve inserted. If that is the reason for blood in the urine, there may be other evidence of disturbed blood clotting such as a propensity to bruise or have nosebleeds or noting blood in the stool.

While keeping fit is to be admired and encouraged, sometimes runners, especially those who cover several miles per day, may see red urine. While this may be due to substances released from damaged muscle cells, true blood can find its way into the urine. Some people think this is due to the bladder walls slapping against each other, so it might be advisable not to urinate immediately before a run and to ensure one is well hydrated. However, even if you think this is the cause, do not be presumptuous and get checked out the first time it happens.

Problems with the kidneys; ureters, the tubes that convey urine into the bladder; or the bladder itself can declare their presence by bleeding. It is easy to imagine a stone rolling around inside these organs abrading tissue and causing bleeding. Likewise tumors, either benign or malignant, as they grow can outstrip their blood supply; little pieces therefore fall off and initiate bleeding. Infections in the urine also cause inflammation, and just as anywhere else in the body, this swollen and irritable tissue has a propensity to bleed.

For women, one must also consider causes that allow blood to enter the urinary flow such as from the vagina, cervix, or uterus.

Prostate problems usually present with an urge to pee, difficulty initiating a flow, poor flow, dribbling, and having to get up at night to urinate, but bleeding can also be a symptom and is to be expected after prostate surgery.

In the movie There Will Be Blood, Daniel Day-Lewis’ performance garnered him an Oscar and Robert Elswit’s cinematography was similarly rewarded. If you see blood in your urine, allow your doctor to capture award-winning images and give yourself an Oscar for being a diligent patient.

Jonathan Sackier
Dr. Jonathan Sackier is an expert in aviation medical concerns and helps members with their needs through AOPA Pilot Protection Services.

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