From the Guidelines
The management of post-traumatic hematuria should prioritize non-invasive management strategies in hemodynamically stable patients with renal injury, as recommended by the American Urological Association (AUA) guidelines 1. The initial approach to post-traumatic hematuria involves assessing the severity of the injury and the stability of the patient.
- Hemodynamic stabilization with intravenous fluids or blood products is crucial if necessary.
- For mild hematuria with stable vital signs, conservative management is appropriate, including:
- Bed rest
- Adequate hydration (2-3 liters of fluid daily)
- Monitoring of urine output and color
- Analgesics such as acetaminophen (500-1000mg every 6 hours) or NSAIDs like ibuprofen (400-600mg every 6-8 hours) can be used for pain control, though NSAIDs should be avoided if significant bleeding is present. Diagnostic evaluation is essential, including:
- Urinalysis
- Complete blood count
- Imaging studies such as CT scan with contrast to assess the extent of urinary tract injury, as recommended by the World Journal of Emergency Surgery 1. For moderate to severe hematuria or hemodynamic instability, urological consultation is warranted, and interventions may include bladder catheterization, angioembolization, or surgical exploration for active bleeding or organ injury 1. Antibiotics (such as ceftriaxone 1-2g IV daily or ciprofloxacin 500mg orally twice daily) may be indicated if there is concern for infection or if instrumentation is required. Follow-up imaging and urinalysis should be performed to ensure resolution of hematuria and to detect any delayed complications such as strictures or pseudoaneurysms. The American Association for Surgery of Trauma (AAST) organ injury scale for kidney trauma should be used to guide management decisions, as outlined in the World Journal of Emergency Surgery guidelines 1.
From the Research
Management of Post-Traumatic Hematuria
The management of post-traumatic hematuria involves a series of evaluations and decisions based on the mechanism of injury, clinical status of the patient, and the degree of hematuria.
- Initial evaluation of hematuria is crucial as it affects the diagnosis, management, and outcome of resultant injuries 2.
- The presence and severity of hematuria can be useful markers of underlying abdominal injury, but only in association with other suggestive clinical signs and symptoms 3, 4.
- In children, a direct relationship between the amount of hematuria and the severity of renal injury has been found, with no normotensive child having a significant renal injury if they have fewer than 50 RBCs per high-power field 4.
- Radiographic evaluation, including computerized tomography, is recommended for patients with 50 or greater red blood cells on urinalysis, hypotension at presentation, or based on the severity of the mechanism of injury 5.
- Selective renal artery embolization can be an effective management strategy for patients with traumatic lesions of the kidney and hematuria, achieving immediate control of hemorrhage in most cases 6.
Evaluation and Imaging
- The decision to perform radiographic evaluation should be based on the degree of hematuria, presence of hypotension, and the mechanism of injury 5, 4.
- Asymptomatic hematuria is a low-yield indication for abdominal CT in children with blunt abdominal trauma, unless accompanied by other suggestive clinical signs and symptoms 3.
- Computerized tomography (CT) of the abdomen is a useful tool in evaluating children with blunt trauma and hematuria, helping to identify renal injuries and other abdominal injuries 3, 4.
Treatment Options
- Transcatheter embolization can be a successful treatment option for patients with renal trauma and uncontrollable hematuria, preserving renal function and viable parenchyma in most cases 6.
- Surgical intervention may be necessary in some cases, such as when embolization is not successful or when there are other associated injuries requiring surgical attention 6.