What is the management of hematuria (blood in urine) after lithotripsy (extracorporeal shock wave lithotripsy, ESWL)?

Management of Hematuria After Extracorporeal Shock Wave Lithotripsy (ESWL)

Hematuria following ESWL is a common and typically self-limiting complication that should be managed conservatively in most cases, with close monitoring for rare but serious complications such as significant hemorrhage or infection.

Expected Post-ESWL Hematuria

• Macroscopic hematuria occurs in approximately 17.2% of patients after ESWL 1
• Hematuria is typically transient and resolves within a few days without specific intervention
• This is considered a normal post-procedural finding related to stone fragmentation and minor tissue trauma

Assessment of Post-ESWL Hematuria

Initial Evaluation

• Determine severity and duration of hematuria
• Assess for associated symptoms:
  • Flank pain beyond expected post-procedural discomfort
  • Fever or chills (suggesting infection)
  • Symptoms of hypovolemia (tachycardia, hypotension)
  • Passage of clots or stone fragments

Warning Signs Requiring Urgent Attention

• Severe, persistent, or worsening hematuria
• Signs of hemodynamic instability
• Fever or other signs of infection
• Severe flank pain disproportionate to expected post-ESWL discomfort
• Inability to urinate due to clots

Management Algorithm

Mild to Moderate Hematuria (Most Common)

1. Conservative management

   • Increased oral hydration to promote urine flow and prevent clot formation
   • Rest and activity limitation for 24-48 hours
   • Analgesics as needed for discomfort
   • Medical expulsive therapy (MET) with α-blockers to facilitate passage of stone fragments 1

2. Monitoring

   • Follow-up imaging within 14 days to assess stone fragmentation and position 2
   • Monitor urine output and color
   • Ensure adequate pain control

Severe or Persistent Hematuria

1. Immediate evaluation

   • Complete blood count to assess hemoglobin/hematocrit
   • Renal function tests
   • Coagulation studies
   • Urinalysis and urine culture to rule out infection

2. Imaging

   • Renal ultrasound or non-contrast CT to evaluate for:
     • Perinephric or subcapsular hematoma
     • Residual stone fragments causing obstruction
     • Hydronephrosis

3. Interventions for complications

   • For significant hematoma with hemodynamic instability: fluid resuscitation, blood transfusion if needed 3
   • For obstructing stone fragments: consider placement of ureteral stent or nephrostomy tube
   • For infection: appropriate antibiotic therapy

Rare but Serious Complications

Significant Renal Hematoma

• Incidence: symptomatic hematoma occurs in approximately 0.21% of cases, asymptomatic in 1.2% 1
• Risk factors: bleeding disorders, anticoagulant therapy, multiple ESWL sessions with short intervals 3
• Management: Most resolve with conservative treatment; severe cases may require angioembolization or surgical intervention

Non-Renal Hemorrhagic Complications

• Rare cases of hepatic subcapsular hematoma have been reported 4
• Management typically conservative unless active bleeding is identified

Anti-GBM Disease

• Extremely rare complication reported months after ESWL 5
• Consider in cases of delayed-onset hematuria with deteriorating renal function
• Requires prompt diagnosis and immunosuppressive therapy

Prevention of Complications in Future ESWL Sessions

• Allow adequate healing time between ESWL sessions (at least 2-4 weeks) 3
• Appropriate management of anticoagulation therapy (ESWL is classified as a procedure with high risk of bleeding) 1
• Ensure proper antibiotic prophylaxis for patients at risk of infection 1
• Use proper technique:
  • Appropriate coupling between treatment head and skin
  • Lower frequency shock waves (60-90/min rather than 120/min)
  • Stepwise energy ramping to minimize renal injury 1

Follow-up Recommendations

• Imaging within 14 days post-procedure to confirm stone fragmentation and clearance
• Increased fluid intake to achieve urine output of at least 2.5 liters daily
• Consider metabolic evaluation to prevent stone recurrence
• Monitor for delayed complications, especially in patients with risk factors

Remember that while hematuria after ESWL is common and typically benign, severe or persistent bleeding requires prompt evaluation to rule out significant complications.