From the Guidelines
The best management for macroscopic hematuria according to the RACGP involves prompt evaluation and referral to a urologist, as recommended by High-Value Care Advice 4: Clinicians should refer for further urologic evaluation in all adults with gross hematuria, even if self-limited 1.
Key Considerations
- Patients with visible blood in the urine should be urgently referred for specialist assessment, ideally within two weeks, due to the significant risk of underlying urological malignancy.
- Initial management includes a thorough history and physical examination, urinalysis, urine culture, full blood count, renal function tests, and coagulation studies.
- Imaging studies such as ultrasound or CT urogram should be arranged, with the choice of imaging modality depending on the clinical scenario and patient factors, as outlined in the American College of Radiology Appropriateness Criteria 1.
- While awaiting specialist evaluation, patients should be advised to increase fluid intake to prevent clot formation and urinary retention.
- Anticoagulant medications may need temporary adjustment in consultation with relevant specialists.
- Pain management with appropriate analgesics may be necessary.
Risk Assessment and Counseling
- The urgency of referral is justified by the 15-20% risk of urological malignancy in patients with macroscopic hematuria, particularly in those over 40 years of age.
- Patients should be counseled about this cancer risk while emphasizing that other benign causes like infection, stones, or benign prostatic hyperplasia are also possible.
- Any patient with hemodynamic instability or severe bleeding requires immediate emergency department referral.
Evidence-Based Recommendations
- The American College of Physicians recommends that clinicians should include gross hematuria in their routine review of systems and specifically ask all patients with microscopic hematuria about any history of gross hematuria 1.
- Clinicians should confirm heme-positive results of dipstick testing with microscopic urinalysis that demonstrates 3 or more erythrocytes per high-powered field before initiating further evaluation in all asymptomatic adults 1.
- Clinicians should pursue evaluation of hematuria even if the patient is receiving antiplatelet or anticoagulant therapy 1.
From the Research
Management of Macroscopic Hematuria
The management of macroscopic hematuria involves a thorough evaluation to determine the underlying cause. According to 2, the initial assessment includes a full blood count, urea and electrolyte levels, midstream urine dipstick, beta human chorionic gonadotrophin, and formal microscopy, culture and sensitivities.
Indications for Admission
Patients with macroscopic hematuria may require admission if they have:
- Clot retention
- Cardiovascular instability
- Uncontrolled pain
- Sepsis
- Acute renal failure
- Coagulopathy
- Severe comorbidity
- Heavy haematuria or social restrictions 2
Follow-up and Referral
Discharged patients should be advised to drink plenty of clear fluids and return for further medical attention if they experience:
- Clot retention
- Worsening haematuria despite adequate fluid intake
- Uncontrolled pain or fever
- Inability to cope at home 2 Follow-up by a urological team should be promptly arranged, ideally within the 2-week cancer referral target 2.
Risk of Malignancy
The risk of malignancy with gross hematuria is greater than 10%, and prompt urologic referral is recommended 3. In men aged >60 years, the positive predictive value of macroscopic haematuria for urological malignancy is 22.1%, and in women of the same age, it is 8.3% 2.
Key Points
- Macroscopic hematuria has a high diagnostic yield for urological malignancy 2
- A thorough history and physical examination are essential to determine potential causes and assess risk factors for malignancy 3
- Patients with macroscopic hematuria should be evaluated promptly, and those with a high risk of malignancy should be referred to a urologist 2, 3