Management of Hematuria with Blood Clots After Lithotripsy
Hematuria with blood clots after lithotripsy is an expected complication occurring in approximately 17% of patients and typically requires conservative management with hydration, monitoring, and delayed resumption of anticoagulation if applicable. 1, 2
Initial Assessment and Monitoring
Reassure the patient that macroscopic hematuria is a common post-lithotripsy finding occurring in 17.2% of cases and usually resolves with conservative measures. 1, 2 However, persistent severe hematuria with clots, flank pain, or hemoglobin drop warrants immediate investigation for more serious complications. 3
Red Flags Requiring Urgent Imaging
Obtain urgent CT scan if the patient develops:
- Severe, persistent flank pain (may indicate subcapsular or perirenal hematoma) 4, 3
- Hemodynamic instability or significant hemoglobin drop (>2 g/dL) 4, 3
- Hematuria persisting beyond 48-72 hours or worsening 3
Perirenal hematoma occurs in only 0.32% of cases but can be life-threatening, with 50% of affected patients having hypertension as a risk factor. 4
Conservative Management Protocol
Hydration Strategy
- Encourage aggressive oral fluid intake to facilitate stone fragment passage and dilute urine. 2, 5
- This helps flush blood clots and residual stone fragments through the urinary system. 5
Pain Management
- Provide adequate analgesia for discomfort during fragment passage, which occurs in approximately 12% of patients. 1, 2
- Consider alpha-blockers (medical expulsive therapy) to enhance stone passage and reduce colic episodes. 1, 6
Anticoagulation Management (Critical Pitfall)
If the patient is on anticoagulation, delay resumption for at least 24 hours postoperatively or until bleeding has almost completely subsided. 1
The specific protocol for anticoagulated patients:
- LMWH resumption should be delayed at least 24 hours after the procedure or longer if significant bleeding persists. 1
- Warfarin can be restarted as early as day 1 postoperatively, but continue LMWH bridging until INR reaches therapeutic range on two separate measurements. 1
- Note that 23% of ureteroscopy patients on bridging protocols required early postoperative blood transfusion coinciding with anticoagulation recommencement. 1
When to Escalate Care
Indications for Blood Transfusion
- Symptomatic anemia or hemoglobin drop requiring transfusion occurred in 4 of 20 patients (20%) with documented perirenal hematoma in one series. 4
- Two of four patients with subcapsular hematoma after ureteroscopy required transfusion. 3
Imaging and Intervention Decisions
Order CT scan immediately if:
- Persistent severe flank pain develops (most common symptom in 90% of hematoma cases) 4
- Hemoglobin drops significantly despite conservative measures 3
- Symptoms appear or worsen 14 days post-procedure (delayed hematoma can occur) 3
Conservative management is successful in the vast majority of cases, even with documented hematoma, and surgical exploration is rarely needed. 4, 3
Steinstrasse Management
Steinstrasse (stone street formation) occurs in 4% of ESWL cases and may present with persistent hematuria and obstruction. 1, 2 While routine pre-stenting doesn't improve stone-free rates, it may reduce steinstrasse formation. 1, 6
If steinstrasse develops with persistent symptoms:
- Continue medical expulsive therapy with alpha-blockers 1
- Consider mechanical percussion and diuretics 1
- Auxiliary procedures are needed in 6-9% of cases 1
Special Populations and Risk Factors
Patients with hypertension and higher BMI have significantly increased risk (p=0.022 and p=0.026 respectively) for perirenal hematoma development. 4 These patients warrant closer monitoring in the immediate post-procedure period.