From the Guidelines
Patients with hematuria should be referred to the Emergency Room when they have gross hematuria accompanied by severe pain, clots that cause urinary obstruction, signs of hemodynamic instability, fever suggesting infection, or recent trauma to the kidneys or urinary tract, as indicated by the American College of Physicians' High Value Care Task Force 1. The evaluation of hematuria is crucial in identifying underlying conditions that may be life-threatening, such as severe infections, bleeding disorders, or obstructive uropathies that can rapidly progress to kidney failure if not promptly addressed.
Key Considerations for Referral to the ER
- Gross hematuria with associated symptoms such as severe pain, clots, or signs of infection
- Hematuria in patients taking anticoagulants who develop significant bleeding
- Patients with a single kidney experiencing hematuria
- Individuals with known urological malignancies who develop new or worsening bleeding
- Any hematuria with acute kidney injury or significantly decreased urine output According to the American College of Physicians' High Value Care Task Force, clinicians should refer for further urologic evaluation in all adults with gross hematuria, even if self-limited 1.
Microscopic Hematuria
While microscopic hematuria can often be evaluated in an outpatient setting, any hematuria with concerning symptoms or signs of underlying conditions requires emergency assessment. The American College of Physicians' High Value Care Task Force also recommends that clinicians should consider urology referral for cystoscopy and imaging in adults with microscopically confirmed hematuria in the absence of some demonstrable benign cause 1.
Importance of Timely Intervention
Patients should not delay seeking care if they experience concerning symptoms, as timely intervention can prevent complications and preserve kidney function. The urgency of referral to the ER is based on the need to identify potentially life-threatening conditions that can rapidly progress to kidney failure if not promptly addressed, as highlighted in the study published in the Annals of Internal Medicine 1.
From the Research
Referral to the Emergency Room (ER)
Patients with hematuria (blood in the urine) should be referred to the Emergency Room (ER) in certain situations, including:
- Gross hematuria, which has a risk of malignancy greater than 10% 2
- Presence of life-threatening and benign processes, such as urologic malignancy, especially in the elderly 3
- Nongenitourinary tract causes that require emergent management 3
- Asymptomatic microscopic and gross hematuria with no identifiable cause after an extensive workup, as these patients should be monitored for early detection of malignancy or occult renal disease 4
Evaluation and Referral
The evaluation of hematuria involves a focused history and physical, including laboratory studies and diagnostic imaging 3. Patients with microscopic hematuria should be referred to urology if no benign cause is found, and those with gross hematuria should be referred promptly due to the higher risk of malignancy 2. However, studies have shown that not all patients with gross hematuria are referred to urology, and few patients with microscopic hematuria are automatically referred 5.
Importance of Prompt Referral
Prompt referral and facilitation of the hematuria evaluation are critical in achieving the best possible outcome and avoiding renal failure or other sequelae of genitourinary disorders 6. Increasing awareness of the complete and timely evaluation of hematuria may be beneficial in preventing delays in diagnosis and treatment, especially in cases of bladder cancer 5.