What is the management of gross hematuria?

Management of Gross Hematuria

Gross hematuria requires prompt urologic referral due to its strong association with urinary tract malignancy (>10% risk) and other potentially serious conditions. 1, 2

Initial Evaluation

Risk Assessment

• Gross hematuria is significantly more concerning than microscopic hematuria
• Risk factors for urinary malignancy include:
  • Age >60 years
  • Male gender
  • Smoking history (especially >30 pack-years)
  • Exposure to industrial chemicals
  • Family history of renal cancer
  • History of pelvic radiation 3

Immediate Steps

1. Confirm true hematuria:

   • Rule out pseudohematuria (medications, foods, myoglobinuria)
   • Document timing (initial, terminal, or total)
   • Note associated symptoms (pain, clots, dysuria)

2. Laboratory evaluation:

   • Complete blood count
   • Serum creatinine and BUN
   • Urinalysis with microscopic examination
   • Urine culture if infection suspected 3

3. Temporary management of active bleeding:

   • Ensure adequate hydration
   • Consider clot evacuation if urinary retention occurs
   • Bladder irrigation may be necessary in severe cases

Diagnostic Workup

Imaging

• CT Urography is the preferred imaging modality (92% sensitivity, 93% specificity) 3
• Alternative imaging options:
  • MR Urography: For patients with contrast allergy or renal insufficiency
  • Renal Ultrasound: Less sensitive (50%) but highly specific (95%) 3

Specialist Referral

• Urologic referral should be made promptly for all patients with gross hematuria 1, 2
• Nephrology consultation if glomerular cause suspected (presence of proteinuria, red cell casts, or renal dysfunction) 3

Cystoscopy

• Essential for all patients with gross hematuria
• Should be performed even if imaging is normal, as it can detect bladder lesions missed by other modalities 3

Common Causes and Specific Management

Urinary Tract Infection

• Treat with appropriate antibiotics based on culture
• Follow-up urinalysis after treatment to confirm resolution of hematuria 1

Urolithiasis

• Pain management
• Medical expulsive therapy or surgical intervention depending on stone size and location 3

Benign Prostatic Hyperplasia

• Alpha-blockers or surgical intervention based on severity 3

Malignancy

• Prompt referral to urologic oncology
• Treatment depends on type, stage, and grade of cancer

Glomerular Disease

• If suspected (based on proteinuria, dysmorphic RBCs, or casts), refer to nephrology
• May require renal biopsy for definitive diagnosis 3

Follow-up

• Even after negative initial evaluation, patients with history of gross hematuria require surveillance
• High-risk patients should have more intensive follow-up with repeat imaging and cystoscopy 3

Common Pitfalls to Avoid

1. Dismissing self-limited gross hematuria: Even a single episode warrants complete evaluation 1
2. Inadequate referral: Studies show only 69-77% of patients with gross hematuria are referred to urology, potentially delaying cancer diagnosis 4
3. Attributing hematuria to anticoagulation: Anticoagulation is not a cause of hematuria but may unmask underlying pathology
4. Incomplete evaluation: Failure to perform both imaging and cystoscopy can miss significant pathology
5. Lack of follow-up: Even with negative initial evaluation, surveillance is necessary due to the intermittent nature of some urologic malignancies 3

Remember that gross hematuria has a significantly higher association with malignancy compared to microscopic hematuria, with risk exceeding 10% 2. Any delay in evaluation may allow serious conditions to progress, potentially affecting morbidity and mortality outcomes 5.