Should a patient with a urinary tract infection (UTI) and recurrent small clots in their urine be referred to urology?

Urinary Tract Infection with Blood Clots: When to Refer to Urology

A patient with UTI and small clots in urine with each infection should be referred to urology for further evaluation, as this may indicate underlying urological pathology requiring specialized assessment.

Understanding Blood Clots in UTIs

Blood clots in urine (hematuria) during UTIs can indicate several conditions:

• Simple inflammation from infection
• Potential structural abnormalities
• Possible urinary tract stones
• Risk of more serious urological conditions

Risk Assessment Factors

When evaluating a patient with UTI and blood clots, consider:

• Frequency of episodes: Recurrent UTIs (defined as ≥3 in 1 year or ≥2 in 6 months) 1
• Persistence of hematuria: Hematuria that persists after treatment
• Complicating factors: Presence of risk factors for complicated UTI

Referral Algorithm for UTI with Blood Clots

1. First-time occurrence with simple UTI:

   • Treat the UTI according to standard guidelines
   • Follow up to ensure resolution of both infection and hematuria
   • If hematuria resolves with treatment, no immediate referral needed

2. Indications for immediate urology referral:

   • Gross hematuria (visible blood) 2
   • Persistent hematuria after UTI treatment
   • Recurrent UTIs with hematuria
   • Complicated UTI with systemic symptoms and hematuria 3
   • Male patients with UTI and hematuria (higher risk of structural abnormalities)

3. Special considerations:

   • Age >40 years increases risk of underlying pathology
   • History of urological conditions
   • Presence of risk factors for urological malignancy

Management Prior to Referral

While arranging urology referral:

• Complete appropriate antibiotic treatment for the current UTI
• Document frequency and characteristics of blood clots
• Consider basic urinalysis and urine culture to guide treatment
• Avoid unnecessary imaging before specialist evaluation 3

What to Expect from Urological Evaluation

The urologist will likely perform:

• Detailed history and targeted physical examination
• Cystoscopy to visualize the bladder and urethra
• Appropriate imaging studies as indicated
• Further specialized testing based on findings

Common Pitfalls to Avoid

1. Dismissing hematuria as "just part of the UTI" - Blood clots warrant proper evaluation, especially if recurrent

2. Overreliance on empiric treatment - Treating symptoms without addressing underlying causes can delay diagnosis of serious conditions

3. Delayed referral - Only 36% of primary care physicians refer patients with microscopic hematuria to urology, potentially delaying diagnosis of significant conditions 2

4. Incomplete follow-up - Failing to confirm resolution of hematuria after UTI treatment

Conclusion

The presence of blood clots with recurrent UTIs warrants urological evaluation. While a single episode with complete resolution may be observed, the pattern described by this patient suggests the need for specialist assessment to rule out underlying urological pathology that may be contributing to both the UTIs and the hematuria.