What is the initial management for a patient presenting with gross hematuria and large clots?

Initial Management of Gross Hematuria with Large Clots

The immediate priority is to prevent clot retention and urinary obstruction through bladder irrigation with a large-bore three-way Foley catheter, while simultaneously assessing hemodynamic stability and initiating resuscitation if needed. 1

Immediate Stabilization and Assessment

Airway and Circulation

• Establish large-bore IV access (largest bore possible, including central access if needed) for potential fluid resuscitation and blood product administration 2, 3
• Administer high FiO2 if the patient shows signs of hemodynamic compromise 2, 3
• Assess hemodynamic status: if a conscious patient is talking and has a palpable peripheral pulse, blood pressure is adequate 2

Bladder Management for Clot Retention

• Insert a large-bore three-way Foley catheter (22-24 Fr) immediately to prevent or relieve clot retention 1
• Initiate continuous bladder irrigation with normal saline to prevent clot formation and maintain catheter patency 1
• If clots are already causing retention, perform manual irrigation to evacuate clots before starting continuous irrigation 1

Baseline Laboratory Assessment

• Obtain full blood count, prothrombin time (PT), activated partial thromboplastin time (aPTT), Clauss fibrinogen, and cross-match 2, 3
• Send midstream urine for formal microscopy, culture and sensitivities 1
• Check urea and electrolytes to assess renal function 1
• Consider beta human chorionic gonadotrophin in women of childbearing age 1

Indications for Immediate Admission

Admit the patient if any of the following are present: 1

• Clot retention (already present with large clots)
• Cardiovascular instability
• Uncontrolled pain
• Signs of sepsis
• Acute renal failure
• Coagulopathy on laboratory testing
• Severe comorbidities
• Heavy ongoing hematuria despite irrigation
• Social restrictions preventing home management

Management of Coagulopathy (If Present)

Established Coagulopathy

• If fibrinogen <1 g/L or PT/aPTT >1.5 times normal, immediately administer fresh frozen plasma (FFP) at 15 ml/kg to prevent established haemostatic failure 2, 3
• For established coagulopathy requiring correction, administer fibrinogen concentrate or cryoprecipitate as the most effective rapid replacement method 2, 3
• Maintain platelet count above 75 × 10^9/L throughout acute management 2, 3

Anticoagulation Reversal

• For warfarin: administer prothrombin complex concentrate (PCC) based on INR (25 u/kg for INR 2-3.9,35 u/kg for INR 4-5.9,50 u/kg for INR >6) plus intravenous vitamin K 5-10 mg 2
• For unfractionated heparin: reverse with protamine (1 mg protamine per 100 units heparin, typically 25-50 mg IV) 2
• For low molecular weight heparin: partial reversal possible with protamine 2
• Direct thrombin and factor Xa inhibitors (dabigatran, rivaroxaban, fondaparinux) cannot be reversed 2

Imaging and Further Investigation

Hemodynamically Stable Patients

• Arrange urgent CT urography with delayed imaging to identify the bleeding source (renal parenchymal injury, stones, masses, or other pathology) 2, 1
• Look for arterial contrast extravasation, which indicates active bleeding requiring intervention 2

Hemodynamically Unstable Patients

• Perform immediate intervention (surgery or angioembolization in specialized centers) if the patient has no or transient response to resuscitation 2
• Do not delay for extensive imaging if the patient remains unstable despite active resuscitation 2

Specific Interventions Based on Etiology

Renal Trauma with Active Bleeding

• In hemodynamically stable patients with arterial contrast extravasation on CT, angiography with super-selective angioembolization should be considered as first choice 2
• Indications for angioembolization include: arterial contrast extravasation, gross non-self-limiting hematuria, arteriovenous fistula, pseudoaneurysm, extended perirenal hematoma, or progressive hemoglobin decrease 2
• If initial angioembolization fails, repeat angioembolization should be considered before surgical intervention 2

Surgical Intervention

• Reserve immediate surgery for hemodynamically unstable patients with no or transient response to resuscitation 2
• The goal of operative exploration is to control bleeding first, repair when possible, and establish perirenal drainage 2

Ongoing Monitoring and Supportive Care

Active Management

• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 2, 3
• Monitor for signs of ongoing bleeding: worsening hematuria, hemodynamic deterioration, or increasing abdominal distention 2
• Regularly reassess coagulation status as it evolves rapidly during active hemorrhage 2

Fluid Management

• Instruct stable patients to drink plenty of clear fluids to help flush clots 1
• In massive hemorrhage scenarios, use warmed blood and blood components rather than crystalloid for volume resuscitation 2

Common Pitfalls to Avoid

• Do not use a small-bore Foley catheter - inadequate for evacuating large clots and will become obstructed 1
• Do not delay catheter insertion - clot retention can rapidly progress to acute urinary retention and renal failure 4
• Do not assume single episode is benign - a single episode of macroscopic hematuria has equal significance to recurrent episodes for malignancy risk (30% in painless hematuria, 22.1% in men >60 years) 1
• Do not send unstable patients to angiography - time-intensive procedures remote from ICU/OR are inappropriate for patients failing resuscitation 2
• Do not forget to anticipate coagulopathy - dilutional coagulopathy develops rapidly with volume resuscitation using crystalloid and red cells without adequate FFP 2

Discharge Instructions (If Stable for Outpatient Management)

Patients should return immediately for: 1

• Clot retention or inability to void
• Worsening hematuria despite adequate fluid intake
• Uncontrolled pain or fever
• Inability to cope at home

Arrange prompt urological follow-up within 2 weeks, as macroscopic hematuria has high diagnostic yield for urological malignancy 1