The Founding Father, the principal author of the Declaration of Independence and the third President of the United States of America, Thomas Jefferson once said: “The tree of liberty must be refreshed from time to time with the blood of patriots and tyrants.”

In medicine, seeing blood should be a warning to us that “The state of our health is fragile and must be refreshed from time to time with reminder that it can be affected by the benign or malignant potential of diseases”

Albert Schweitzer, the German Theologian, Physician, Philosopher and Medical Missionary in the last century stated: “An optimist is a Person who sees green light everywhere, while a pessimist sees only the red stoplight, the truly wise person is colour-blind”

When it comes to sign of diseases, it is a fine line that separates the optimists and pessimists.

The idealists or a Utopian have the positive attitude to accept many signs and symptoms affecting them and miscalculate the odds of a serious disease looming.

On the other hand, the realists and the pragmatists have the negative impressions on indicators resulting overestimations of the possibility of ailments.

In reality, it is almost impossible to be “The truly wise colorblind” who strikes the balance in healthy approach to the signals our body is sending to us.

This week we tackle the issue of seeing painless red urine may not necessary be pain-free for a reader.

Dear Dr. G,

I am 52 year old and have been married for thirty years. I have been troubled with the problems of occasional erectile dysfunction that had affected my relationship with my wife aged 46, for the last six months.

Truthfully, the ED is not that bad. I am OK to achieve the erection (most of the time) but the trouble really is to sustain the rigidity. Is this really considered as ED?

I admit I am a smoker, bit overweight and have blood pressure issues. My doctor also asked me to be a bit more careful with my diet because of high cholesterol and the family history of diabetes. But, I am healthy.

I am writing to you to ask whether I am a suitable candidate to take the blue pills?

Also, by the way, I just would like to let you know I recently had two episodes of blood in urine. I mean they are nothing serious and it was completely painless.

I am sure it must be some food I ate and not related to the sexual problems, right?

Please help.


Blood in the urine is also known as hematuria. The urine can be visibly discoloured (Gross hematuria) or detectable only with microscope (microscopic hematuria).  Hematuria can be presented with or without the association of pain.

The sufferers usually consider the lack of pain to be associated with less serious etiology of hematuria. The irony is the painlessness should raise the Red flag of the possibility of malignant conditions, especially in high-risk individuals who are smokers.

In fact, one of the few lessons we learnt in medical school is “Painless hematuria is cancer until proven otherwise!”

Blood in the urine can originate from various parts of the urinary tract including the kidneys, ureters, bladder, prostate and urethra. Physician should carefully evaluate any degree of bleeding, even it resolves spontaneously.

Although conditions such as infections, kidney stones and trauma are more commonly linked to bloody urine, these conditions are usually associated with some degree of pain.

The painless nature of blood in the urine can be associated with blood thinning agents such as aspirin and warfarin.

On the other spectrum, the looming possibility of cancer such as bladder or kidneys, especially in heavy smoker, must be excluded. The pattern of the bleeding, such as the initiation, during or the end of micturition can usually give a clue of the source of the problem.

The state of the art investigations for painless gross hematuria is a contrasted CT scan and Flexible cystoscopy. The former involves the patients going through a scanner in a tunnel to delineate the detailed anatomy of the urinary tract.

Despite a normal CT scan, the sufferers are usually advised to endure a cystoscopic examination, which usually involve the insertion of a fiber optic camera into the penis (OUCH!) to find the source of the bleeding.

Johan is an ideal candidate to be treated with the blue pill. Although he is able to achieve erection for penetration, the inability to sustain such rigidity is by definition an Erectile Dysfunction.

The reversal of sedentary lifestyle that induces dyslipidemia, hypertension and glucose intolerance are also essential to prevent the worsening of the sexual dysfunction.

Katharine Whitehorn, the British Journalist who is known for her wit in her columns once said: “The Disease is Painless, it’s the cure that hurts”.

Bleeding is usually a signaling of Red Alerts from our body. Although seeing Red may be painless on presentation, the path to identify and solving the problem may not be necessary pain-free.

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