7 Causes of Painless Blood on Tissue After Urinating.

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Key facts:

Painless blood on tissue after urination can arise from the urinary tract (true hematuria) or the reproductive tract (false hematuria).

Possible causes of blood in tissue after urinating (without pain) may include (reference):

  • Bladder cancer.
  • Exercise-induced hematuria.
  • Silent stones.
  • Enlarged prostate.
  • Glomerular diseases.
  • Vaginal bleeding (false hematuria).
  • Urethral diverticulum
  • Silent UTI.
  • Others:
    • Endometriosis of the urinary system.
    • Trauma to the urethra, the bladder, or the kidneys (doesn’t necessarily cause pain).
    • TB of the urinary bladder.
    • Recent catheterization or cystoscopy.
    • Recent stone lithotripsy (destructing the stone with an ultrasound device).
    • Bleeding disorders or anticoagulant medications.
    • Urethral stricture.
    • polycystic kidney disease
    • Pyelonephritis.
    • Renal vein thrombosis.
    • Renal artery embolism.
    • Arteriovenous malformations in the kidney.
    • Severe hypertension (malignant hypertension).
    • Kidney tumors (benign or malignant).
    • Polycystic kidney.
    • Hydronephrosis.
    • Hypercalciuria.
    • Drugs such as phenytoin, Pyridium, rifampin, and nitrofurantoin.

Some clinical clues to the cause of blood on tissue after peeing:

CONDITIONLANDMARK FEATURES
Bladder cancer.Old male, smoker, & painless blood on the tissueExercise-indued hematuriaBlood on tissue after strenuous exercises such as marathon running or heavy contact sports.
Silent kidney stones.Known to have kidney stones or previous attacks of loin pain before the appearance of blood on tissue after urinating
Vaginal bleedingInspecting the area around the urethra in females may reveal the vaginal blood mistaken for hematuria.
Prostatic conditionsoften affects old males. Difficult and intermittent urination and urine dripping are important signs of prostate enlargement.
Urethral diverticulumIt is common in females. A tender vaginal mass is often felt in its upper wall.

1. Bladder cancer (rare but serious).

Bladder cancer is the commonest malignancy of the urinary tract. It is more common in males than females (male to female ratio is about 3:1) (reference).

You should consider bladder cancer as a cause of blood on the tissue, especially if you have risk factors such as:

  • Cigarette smoking.
  • Being older (more than 50).
  • Being male.
  • Opium use.
  • Occupation exposure to carcinogens as with metal workers, painters, rubber industry workers, leather workers, textile and electrical workers, miners, cement workers, transport operators, excavating-machine operators, and jobs that involve the manufacture of carpets, paints, plastics, and industrial chemicals.
  • Genetics also plays a role.
  • Schistosomiasis infection (common in north Africa and Japan).
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Symptoms of urinary bladder cancer:

  • Early bladder cancer may present with irritative symptoms such as painful urination (dysuria), the urgency to urinate, or frequent urination.
  • Typically, bladder cancer causes painless bleeding in the urine (intermittent attacks of bloody urine or blood on tissue after urination).
  • Blood is often present throughout the urination, but minor bleeding (appears on tissue) also occurs.
  • Bladder pain or pressure in the lower abdomen (typically, no pain is present in patients with bladder cancer).
  • Dysuria or pain after the end of urination.
  • Signs of metastasis may also exist, such as bone pain, abdominal pain, liver pain, headache, or blurring of vision.
  • Weight loss, anorexia, and other systemic symptoms may also present.

Call your doctor immediately if you have blood after urination associated with other risk factors and symptoms of UB.

The diagnosis of urinary bladder (UB) cancer is often made by finding malignant cells in the urine, UB imaging (ultrasound or CT scan), or cystoscopy and bladder biopsy.

2. False hematuria (vaginal bleeding).

In my opinion, as a doctor, females should put the possibility of vaginal bleeds as the most likely cause of blood on tissue after peeing.

The female reproductive system is a common source of bleeding that may contaminate urine during wiping with a tissue giving a false impression of bloody urine (hematuria).

So it is important for you as a female to inspect the area around the urethral and vaginal openings to accurately determine the source of bleeding (urethral versus vaginal).

Common causes of vaginal bleeding that may mimic blood in the urine (with no pain):

  • Menses.
  • Spotting (due to hormonal fluctuations).
  • Use of OCPs.
  • Pregnancy.
  • Ectopic pregnancy.
  • Intrauterine device (IUD).
  • Sexual intercourse.
  • During the times before and just after menopause.
  • Miscarriage (before the 20th week of pregnancy.
  • Vaginal atrophy (post-menopausal).

Learn more about vaginal bleeding.

3. Prostatic conditions (Men-only).

The prostate is a small organ that lies just below the urinary bladder (in men only). In many cases, the prostate can be the source of blood on tissue after urinating.

Benign prostatic hypertrophy (BPH) is the most common prostate disease. It is extremely common, and its prevalence increases with age; for example (reference):

  • Affects 50% of men over 50 years.
  • Affects about 80% of men over 80 years.
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BPH often doesn’t cause blood in the urine. However, chronic obstruction of the urine streams may predispose to complications such as bladder stones, UTI, bladder diverticulum, or prostate cancer.

Blood on tissue after urination in older males should be investigated due to the high prevalence of bladder cancer and BPH and its associated complications.

Symptoms of BPH:

  • Asymptomatic: many older men with BPH don’t have any symptoms at all (no pain or urine obstruction)
  • Storage symptoms: Increased urinary frequency, sudden urge to urinate, urine incontinence, and waking up more often to urinate at night (nocturia).
  • Slow urinary stream.
  • Straining to urinate.
  • Intermittent urination (stream starts and stops several times during urination).
  • Splitting of the urine stream.
  • Dripping of some urine drops after urination.
  • In complicated cases, drops of blood or blood on tissue after urinating. Pain may or may not be present.

Other prostatic conditions that may cause blood on tissue after urination in males:

  • Prostate cancer.
  • Chronic prostatitis.
  • Trauma to the prostate.
  • Recent operations in the prostate.
  • Taking a biopsy from the prostate.

4. Exercise-induced hematuria.

Exercise-induced hematuria can occur with (reference):

  • Vigorous contact sports such as boxing and football.
  • Non-contact sports such as marathon running, rowing, and swimming.
  • It can also occur with long-distance cycling (but rare).

Possible mechanisms (reference):

  • Traumatic: trauma to the kidneys or the urinary bladder with vigorous contact sports or long-distance running.
  • Blood shifting from the kidneys to the muscle leads to ischemic inflammation of the kidneys.
  • Lactic acidosis from excessive muscle work makes your kidneys more permeable to red blood cells (hence the blood appears in urine).

Symptoms and features:

  • Often starts after stressful or prolonged sports such as boxing, football, marathon running, etc.
  • It may be associated with bladder or kidney pain.
  • The condition improves with rest (after a few days to one week).
  • Often, it doesn’t lead to significant kidney disease or kidney failure.
  • Imaging studies (such as Ultrasound or CT scans) are often normal.
  • Your doctor should thoroughly investigate hematuria that continues for more than a week from the last exercise.
  • Exercise-induced hematuria in people above 50 should also be investigated thoroughly due to the high risk of bladder cancer.

5. Urethral diverticulum

The urethral diverticulum is a localized dilatation or pouch in the female urethra (common in the middle portion of the urethra).

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Urethral diverticulum is a common condition affecting up to 5% of women (reference).

The diverticulum can cause pain or discomfort in the female urethra without UTI. Also, it can cause blood on tissue after urination in females.

Symptoms (reference):

  • Urethral pain (may be in the form of mild discomfort or weird feeling without frank pain).
  • Dripping of urine after peeing.
  • Tender vaginal mass (felt in its anterior wall).
  • Painful intercourse.
  • Dysuria (pain during urination).
  • Chronic or recurrent UTIs.
  • Increased frequency of urination with urinary urgency.
  • Bloody urethral discharge. The blood may appear during or after urination. It also may appear on the tissue after peeing).
  • Urinary incontinency.
  • Urine retention.

6. Others.

The causes of blood in the urine are endless. Most of the causes are transient and often resolve on their own. However, you should always discuss the issue with your doctor if they cannot find an explanation for the blood on the tissue after urination.

Other possible causes include the following:

  • Silent (painless) stones in the kidney or urinary bladder.
  • Silent (painless) cystitis.
  • Endometriosis of the urinary system.
  • Trauma to the urethra, the bladder, or the kidneys (doesn’t necessarily cause pain).
  • TB of the urinary bladder.
  • Recent catheterization or cystoscopy.
  • Glomerular diseases (often cause hematuria through the urine stream and not blood on tissue after peeing).
  • Recent stone lithotripsy (destructing the stone with an ultrasound device).
  • Bleeding disorders or anticoagulant medications.
  • Urethral stricture.
  • polycystic kidney disease
  • Pyelonephritis.
  • Renal vein thrombosis.
  • Renal artery embolism.
  • Arteriovenous malformations in the kidney.
  • Severe hypertension (malignant hypertension).
  • Kidney tumors (benign or malignant).
  • Polycystic kidney.
  • Hydronephrosis.
  • Hypercalciuria.
  • Drugs such as phenytoin, Pyridium, rifampin, and nitrofurantoin.