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

Management of Gross Hematuria

Patients presenting with gross hematuria require prompt and thorough evaluation to identify potentially serious underlying conditions, as delays in evaluation can be associated with decreased survival. 1

Initial Evaluation

1. Laboratory Assessment

   • Complete urinalysis with microscopic examination
   • Urine culture to rule out infection
   • Complete blood count
   • Renal function tests (BUN, creatinine) 1
   • Assess for signs of glomerular disease (dysmorphic RBCs, RBC casts) 1

2. Risk Stratification

   • High-risk factors:
     • Age (women ≥50 years, men ≥40 years)
     • Smoking history >30 pack-years
     • Gross hematuria
     • History of pelvic radiation
     • Chronic urinary infections
     • Occupational exposures 1

Imaging and Diagnostic Workup

1. Imaging Selection Based on Clinical Presentation:

   • For patients with suspected urolithiasis: Ultrasound as first-line imaging 1
   • For patients with pelvic fracture and gross hematuria: Retrograde cystography (absolute indication) 2
   • For high-risk patients: CT urography (sensitivity 92%, specificity 93%) 1
   • For patients with renal insufficiency or contrast allergy: MR urography or ultrasound 1

2. Cystoscopy

   • Indicated for all patients with gross hematuria, particularly those with risk factors for bladder cancer 1
   • Should be considered if Hunner lesions are suspected in patients with chronic symptoms 1

3. Special Considerations for Trauma Patients

   • For blunt trauma with gross hematuria and pelvic fracture, retrograde cystography is mandatory 2
   • Technique for cystography:
     • Retrograde, gravity filling of bladder with contrast
     • Minimum volume of 300 mL or until patient tolerance
     • At least two views: maximal fill and post-drainage 2

Management Based on Diagnosis

1. Intraperitoneal Bladder Rupture

   • Surgical repair is mandatory for intraperitoneal bladder rupture from blunt or penetrating trauma 2
   • Failure to repair can result in peritonitis, sepsis, and other serious complications 2

2. Urinary Tract Infection

   • Appropriate antibiotics based on culture and sensitivity 1

3. Urolithiasis

   • Pain management and appropriate urological referral 1

4. Benign Prostatic Hyperplasia

   • Medical or surgical management based on severity 1

5. Malignancy

   • Prompt referral to urology for definitive management 1

6. Autosomal Dominant Polycystic Kidney Disease (ADPKD)

   • Evaluate for cyst hemorrhage, infection, stones, or malignancy 3

Follow-up Recommendations

• If initial evaluation is negative but hematuria persists, yearly urinalyses are recommended 1
• If a patient with persistent asymptomatic microhematuria has two consecutive negative annual urinalyses, no further evaluation is necessary 1
• For persistent or recurrent hematuria after initial negative workup, consider repeat evaluation within 3-5 years 1

Common Pitfalls to Avoid

1. Assuming benign cause without complete evaluation in high-risk patients 1
2. Inadequate imaging (e.g., using ultrasound alone in high-risk patients) 1
3. Sex disparities in referral patterns - patients should be referred regardless of sex 1
4. Delaying or deferring investigation of hematuria, which may permit disease progression 4
5. Failing to perform cystography in patients with pelvic fracture and gross hematuria 2
6. Using inadequate technique for cystography - simply clamping a Foley catheter to allow excreted IV contrast to accumulate is insufficient 2

Gross hematuria should never be ignored as it can be the first manifestation of serious urological conditions including malignancy, and timely evaluation is essential to prevent disease progression and improve outcomes.