What is the management approach for a patient presenting with gross hematuria?

Management of Gross Hematuria

Patients presenting with gross hematuria require immediate evaluation with retrograde cystography if there is suspicion of bladder injury, especially in the setting of pelvic fractures, and surgical repair is mandatory for intraperitoneal bladder ruptures. 1

Initial Assessment

• Immediate Evaluation:

  • Assess hemodynamic stability
  • Determine if trauma is involved (blunt or penetrating)
  • Check for associated symptoms (pain, clots, frequency)
  • Evaluate for risk factors for malignancy (age >60, smoking history, chemical exposure) 2

• Laboratory Tests:

  • Complete blood count
  • Serum creatinine and BUN
  • Urinalysis with microscopic examination
  • Urine culture if infection is suspected 2

Diagnostic Imaging

• For trauma patients:

  • IV contrast-enhanced abdominal/pelvic CT with immediate and delayed images for suspected renal injury 1
  • Retrograde cystography for patients with gross hematuria and concerning mechanism for bladder injury 1

• For non-trauma patients:

  • CT Urography is preferred for detecting stones, malignancy, and structural abnormalities
  • MR Urography if contrast allergy or renal insufficiency exists
  • Renal ultrasound as an alternative, especially in younger patients 2

Management Algorithm

1. Trauma-Related Gross Hematuria

• If hemodynamically stable:

  • Non-invasive management strategies for renal injury 1
  • Observe patients with renal parenchymal injury and urinary extravasation 1
  • Perform follow-up CT imaging for deep lacerations (AAST Grade IV-V) or clinical signs of complications 1

• If hemodynamically unstable:

  • Immediate intervention (surgery or angioembolization) 1
  • For bladder injuries:
    • Surgical repair is mandatory for intraperitoneal bladder rupture 1
    • Extraperitoneal bladder ruptures may be managed with catheter drainage

2. Non-Trauma Gross Hematuria

• Urologic referral is indicated for:

  • All cases of gross hematuria (risk of malignancy >10%) 3
  • Age >60 years with unexplained hematuria
  • Recurrent UTIs 2

• Nephrology referral if:

  • Glomerular disease is suspected (especially with proteinuria)
  • Continuously decreasing eGFR
  • eGFR <30 mL/min/1.73 m² 2

Special Considerations

• For specific conditions:
  • ADPKD: Evaluate for cyst hemorrhage, cyst infection, urinary tract infection, renal stones 4
  • Pediatric patients: Consider IgA nephropathy, thin basement membrane nephropathy, post-streptococcal glomerulonephritis 2, 5

Follow-up and Surveillance

• After treatment of infection, repeat urinalysis 1-2 weeks after completing antibiotics
• For patients with risk factors for malignancy:
  • Urine cytology and repeat urinalysis at 6,12,24, and 36 months 2
  • Surveillance with repeat imaging and cystoscopy for high-risk patients 2

Common Pitfalls to Avoid

• Delaying evaluation: Any gross hematuria warrants thorough investigation, as the risk of malignancy exceeds 10% 3
• Inadequate imaging: For cystography, ensure minimum 300 mL of contrast is instilled for maximal bladder distention 1
• Missed referrals: Studies show primary care physicians often hesitate to refer patients with gross hematuria to urology (only 64% referred older males with painless gross hematuria) 6
• Assuming benign cause: Even with normal renal ultrasound, relapsing episodes of gross hematuria can be caused by renal tumors 5

Remember that gross hematuria should always trigger a thorough urologic investigation, as delaying or deferring careful investigation may permit significant disease processes to become more extensive 7.