What is the initial management for a patient with severe hematuria (blood in urine)?

Initial Management of Severe Hematuria

For patients with severe hematuria, immediate urologic referral and evaluation with cystoscopy and upper tract imaging is essential to rule out potentially life-threatening conditions including genitourinary malignancy. 1

Initial Assessment

Immediate Steps

• Assess hemodynamic stability (vital signs, orthostatic changes)
• Obtain IV access with large-bore catheter (16-18G)
• Consider bladder catheterization with three-way Foley catheter for continuous bladder irrigation if clots are present
• Laboratory evaluation:
  • Complete blood count
  • Coagulation studies (PT/INR, PTT)
  • Comprehensive metabolic panel (renal function)
  • Type and cross-match if significant blood loss

Risk Stratification

Severe hematuria (gross hematuria) is automatically considered high-risk and requires urgent evaluation regardless of other factors 2, 1. Additional risk factors that increase urgency include:

• Age >60 years
• Smoking history (especially >30 pack-years)
• Male gender
• Occupational exposure to chemicals or dyes
• History of urologic disorders
• Anticoagulant use (though this does not explain hematuria)

Diagnostic Workup

Laboratory Tests

• Urinalysis with microscopic examination to confirm hematuria and assess for:
  • RBC morphology (dysmorphic RBCs suggest glomerular source)
  • Presence of casts, crystals, or pyuria
  • Proteinuria
• Urine culture to rule out infection
• Serum creatinine and BUN to assess renal function

Imaging

• CT Urography is the preferred initial imaging modality for severe hematuria due to its high sensitivity (92%) and specificity (93%) for detecting urinary tract pathology 1
• For patients with renal insufficiency or contrast allergy:
  • MR urography or
  • Renal/bladder ultrasound

Cystoscopy

• Indicated for all cases of gross hematuria
• Should be performed promptly to directly visualize the bladder and urethra

Management Algorithm

1. Stabilize the patient

   • Fluid resuscitation if hemodynamically unstable
   • Transfusion if significant blood loss (Hgb <7-8 g/dL)

2. Control active bleeding

   • Continuous bladder irrigation with normal saline if clots present
   • Consider clot evacuation if large clot burden

3. Determine source of bleeding

   • Upper tract (kidney/ureter): CT urography or MR urography
   • Lower tract (bladder/urethra): Cystoscopy

4. Specialist referral

   • Urology referral is mandatory for all cases of gross hematuria 1, 3
   • Consider concurrent nephrology referral if:
     • eGFR <60 ml/min/1.73m²
     • Significant proteinuria
     • Dysmorphic RBCs or red cell casts

Common Causes of Severe Hematuria

• Urologic malignancy (bladder, kidney, prostate)
• Urolithiasis
• Urinary tract infection
• Benign prostatic hyperplasia
• Trauma
• Renal disease (glomerulonephritis)
• Anticoagulant therapy (contributing factor, not primary cause)

Important Caveats

• The risk of malignancy with gross hematuria exceeds 10%, mandating thorough evaluation 3
• Never attribute hematuria solely to anticoagulant therapy without complete evaluation 1
• Patients with trauma and gross hematuria require immediate imaging 2
• Even if initial evaluation is negative, patients with persistent hematuria require continued surveillance 2, 1

Remember that severe hematuria is a symptom, not a diagnosis, and identifying the underlying cause is critical for appropriate management and preventing morbidity and mortality.