What are the American Urological Association (AUA) guidelines for managing gross hematuria?

From the Guidelines

The American Urological Association (AUA) guidelines recommend that clinicians refer all adults with gross hematuria for further urologic evaluation, even if self-limited, as stated in High-Value Care Advice 4 by the American College of Physicians 1.

Key Recommendations

• 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, as advised in High-Value Care Advice 1 1.
• Gross hematuria warrants a comprehensive evaluation, including a complete history, physical examination, laboratory tests (such as complete blood count, coagulation studies, renal function tests, and urinalysis), and imaging studies (starting with renal ultrasound, followed by CT urography if no contraindications exist) to identify the underlying cause.
• Cystoscopy is essential for evaluating bladder and urethral sources of bleeding, and clinicians should consider urology referral for cystoscopy and imaging in adults with microscopically confirmed hematuria in the absence of a demonstrable benign cause, as suggested in High-Value Care Advice 5 1.

Evaluation and Management

• The initial evaluation of gross hematuria should focus on assessing the patient's hemodynamic stability and addressing any life-threatening bleeding with fluid resuscitation and blood transfusions if necessary.
• For patients with active bleeding, continuous bladder irrigation with normal saline via a three-way Foley catheter may be the first-line intervention, followed by clot evacuation if necessary.
• The underlying etiology (infection, malignancy, stones, BPH) must be treated specifically to prevent recurrence, and patients on anticoagulants may require temporary discontinuation or reversal in consultation with appropriate specialists.

Important Considerations

• 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, as recommended in High-Value Care Advice 3 1.
• Urinary cytology or other urine-based molecular markers for bladder cancer detection should not be obtained in the initial evaluation of hematuria, according to High-Value Care Advice 7 1.

From the Research

American Urological Association (AUA) Guidelines for Managing Gross Hematuria

The AUA guidelines for managing gross hematuria are not explicitly stated in the provided studies. However, the following information can be gathered:

• Gross hematuria is defined as the presence of blood in the urine, either on voiding or in a catheterized specimen 2.
• The risk of malignancy with gross hematuria is greater than 10%, and prompt urologic referral is recommended 3.
• Clinical evaluation may be guided by the patient's age, sex, medical history, and physical examination 4.
• A thorough urologic investigation should be triggered by the presence of gross hematuria, which can include:
  • Laboratory tests to assess renal function
  • Imaging tests such as ultrasound, computed tomography urography, or magnetic resonance urography
  • Cystoscopy
  • Referral to a nephrologist or urologist for further assessment if required 3, 4, 5, 6
• Patients with gross hematuria should be followed semi-annually for 3 years, even if the initial workup is negative 6.

Diagnostic Techniques

The following diagnostic techniques can be used to evaluate gross hematuria:

• Plain X-rays of the kidney, ureter, and bladder
• Ultrasound
• Intravenous urography
• Computed tomography (CT)
• Magnetic resonance imaging
• Retrograde ureterography and pyelography (RGP)
• Cystoscopy
• Ureteroscopy 2
• CT urography, which includes an unenhanced scan, the nephrographic phase, and the excretory phase, can be used alone for the evaluation of gross hematuria 2.