From the Guidelines
Management of hematuria requires a systematic approach based on the severity and underlying cause, with the primary goal of controlling bleeding while addressing the underlying etiology, as recommended by the American College of Radiology in 2020 1. The initial evaluation should include a thorough history, physical examination, urinalysis, and urine culture to determine if the bleeding is from the upper or lower urinary tract.
- For gross hematuria with clots causing urinary retention, placement of a large-bore urinary catheter (20-24 French) with gentle irrigation using normal saline is recommended.
- Patients with significant bleeding may require continuous bladder irrigation using a three-way catheter with normal saline at 100-200 mL/hour, adjusting the rate to maintain clear or pink urine.
- For medication-induced hematuria, the offending agent should be discontinued if possible.
- Anticoagulant-related hematuria may require dose adjustment or reversal agents in severe cases.
- Infection-related hematuria typically resolves with appropriate antibiotics such as ciprofloxacin 500 mg twice daily or nitrofurantoin 100 mg twice daily for 7-14 days.
- For radiation cystitis, treatments include hyperbaric oxygen therapy, intravesical instillations of hyaluronic acid, or formalin in severe cases. Patients with gross hematuria should undergo a full urologic workup, as the risk of malignancy is high, up to 30-40% 1. Patients with microhematuria have a low risk of malignancy, ranging from 2.6% to 4%, and in most patients with asymptomatic microhematuria, a cause is never found 1. The American College of Physicians recommends confirming 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. The management approach should be tailored to the specific cause, with the primary goal of controlling bleeding while addressing the underlying etiology, and maintaining adequate hydration is important in all cases to prevent clot formation and urinary retention.
- Patients with persistent or recurrent hematuria require referral to urology for cystoscopy and upper tract imaging to rule out malignancy.
- Clinicians should pursue evaluation of hematuria even if the patient is receiving antiplatelet or anticoagulant therapy 1.
From the Research
Classification and Risk Factors
- Hematuria is classified as either gross (macroscopic) or microscopic 2, 3, 4
- Gross hematuria has a risk of malignancy greater than 10%, and prompt urologic referral is recommended 2
- Microscopic hematuria most commonly has benign causes, such as urinary tract infection, benign prostatic hyperplasia, and urinary calculi 2
Diagnostic Approach
- A thorough history and physical examination are necessary to determine potential causes and assess risk factors for malignancy 2, 3
- The approach to diagnosis and investigation of hematuria differs depending on whether the hematuria is macro- or microscopic 3
- Clinical presentation and urine microscopy can differentiate glomerular from non-glomerular hematuria 4
Investigation and Management
- Laboratory tests, imaging of the urinary tract, and referral to nephrology and urology subspecialists may be necessary to rule out intrinsic renal disease and other causes of hematuria 2, 4, 5, 6
- Recommended investigations for hematuria include computed tomography intravenous pyelogram, urine cytology, urine microscopy and culture, and blood tests 5
- Patients with risk factors for genitourinary malignancy, macroscopic hematuria, or those in whom no cause is found, should be referred to a urological service for further investigation including cystoscopy 5
Treatment and Follow-up
- There is no specific treatment to resolve or prevent hematuria, and resolution usually occurs with appropriate management of the underlying disorder 4
- Persistent microscopic hematuria indicates the presence of a renal disease that warrants close monitoring and evaluation 4
- Prompt referral to a pediatric nephrologist is indicated in situations when hematuria does not resolve within 2 weeks of onset of glomerulonephritis, or when there is a need for a renal biopsy or specific urine biochemistry testing or imaging studies 4