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

Management of Gross Hematuria

Any patient presenting with large amounts of visible blood in the urine requires urgent urologic evaluation with cystoscopy and upper tract imaging (CT urography), regardless of whether the bleeding stops on its own, because gross hematuria carries a 30-40% risk of malignancy. 1, 2

Immediate Stabilization and Assessment

Hemodynamic Status

• Assess hemodynamic stability first - if the patient is hypotensive or showing signs of shock from blood loss, immediate resuscitation with IV fluids and blood products takes priority over diagnostic workup 1
• In hemodynamically unstable patients with no or transient response to resuscitation, immediate surgical intervention or angioembolization is required 1
• Hemodynamically stable patients should proceed with diagnostic evaluation before any intervention 1

Acute Urinary Retention Management

• If the patient develops clot retention (inability to void due to blood clots blocking the bladder), place a large-bore three-way Foley catheter (22-24 Fr) and initiate continuous bladder irrigation with normal saline 3
• Emergency surgical intervention for clot evacuation is rarely needed but may be required if irrigation fails 3

Trauma-Related Considerations

If there is ANY history of trauma (even minor), this changes the evaluation pathway:

• Perform retrograde cystography (plain film or CT) in stable patients with gross hematuria and pelvic fracture to evaluate for bladder rupture 1
• Perform IV contrast-enhanced abdominal/pelvic CT with immediate and delayed images when there is suspicion of renal injury 1
• Blood at the urethral meatus with pelvic fractures or straddle injury requires retrograde urethrography before catheter placement 2
• Intraperitoneal bladder ruptures from trauma must be surgically repaired - they will not heal with catheter drainage alone 1

Non-Traumatic Gross Hematuria Workup

Confirm True Hematuria

• Verify this is actual blood in urine, not pseudohematuria from foods (beets), medications (rifampin, phenazopyridine), or menstrual contamination 2
• Obtain urinalysis with microscopy to confirm ≥3 RBCs per high-power field 2, 4

Mandatory Diagnostic Studies

Complete urologic evaluation includes:

1. Multiphasic CT urography (unenhanced, nephrographic phase, and excretory phase) - this is the preferred imaging modality to detect renal cell carcinoma, transitional cell carcinoma, and urolithiasis 2, 3

   • If CT is contraindicated due to renal insufficiency or contrast allergy, use MR urography or renal ultrasound with retrograde pyelography as alternatives 2

2. Flexible cystoscopy - mandatory for all patients with gross hematuria to visualize bladder mucosa, urethra, and ureteral orifices 2, 3

   • Flexible cystoscopy is preferred over rigid because it causes less pain with equivalent or superior diagnostic accuracy 2

3. Voided urine cytology - obtain in high-risk patients (age >60, smoking history, occupational chemical exposure) to detect high-grade urothelial carcinomas 2, 3

4. Laboratory tests:

   • Serum creatinine and BUN to assess renal function 2
   • Complete blood count to evaluate degree of blood loss 2
   • Urine culture if infection is suspected (fever, dysuria, urgency) - but do NOT delay cancer workup for empiric antibiotic treatment 2

Assess for Glomerular vs. Urologic Source

Look for features suggesting glomerular disease (which requires nephrology referral IN ADDITION to completing urologic evaluation, not instead of it):

• Tea-colored or cola-colored urine (rather than bright red) 2
• Significant proteinuria (>2+ on dipstick or protein-to-creatinine ratio >0.5 g/g) 2
• Dysmorphic RBCs >80% on microscopy 2
• Red blood cell casts (pathognomonic for glomerular disease) 2
• Elevated serum creatinine suggesting renal insufficiency 2

Critical point: The presence of glomerular features does NOT eliminate the need for urologic evaluation - malignancy can coexist with medical renal disease 2

Special Clinical Scenarios

Angioembolization Indications

In hemodynamically stable or stabilized patients, angiography with super-selective angioembolization is indicated for: 1

• Arterial contrast extravasation on CT
• Pseudoaneurysms
• Arteriovenous fistula
• Non-self-limiting gross hematuria with active bleeding on angiography

When Antibiotics Are NOT the Answer

• Do not prescribe empiric antibiotics for gross hematuria without clear evidence of infection (fever, pyuria, positive urine culture) 2
• Persistent hematuria despite 2 months of appropriate antibiotic therapy effectively rules out simple UTI and strongly suggests malignancy requiring urgent evaluation 2
• Prescribing additional antibiotics delays cancer diagnosis and provides false reassurance 2

Common Pitfalls to Avoid

1. Never ignore gross hematuria even if self-limited - 30-40% malignancy risk mandates complete evaluation 1, 2

2. Do not defer evaluation due to anticoagulation or antiplatelet therapy - these medications may unmask underlying pathology but do not cause hematuria themselves 2, 5

3. Do not attribute hematuria to benign prostatic hyperplasia without proving it - BPH can cause hematuria but does not exclude concurrent malignancy 2

4. Do not delay urologic referral to treat presumed UTI - if infection is suspected, obtain urine culture and refer urgently while awaiting results 2

5. Delays beyond 9 months from first hematuria presentation are associated with worse cancer-specific survival in bladder cancer patients 2

Follow-Up Protocol

If the complete workup is negative: 2

• Repeat urinalysis, urine cytology, and blood pressure at 6,12,24, and 36 months
• Immediate re-evaluation is warranted if:
  • Recurrent gross hematuria
  • Significant increase in microscopic hematuria
  • New urologic symptoms (irritative voiding, flank pain)
  • Development of hypertension or proteinuria

The bottom line: Gross hematuria is a red flag for malignancy until proven otherwise, requiring urgent and complete urologic evaluation regardless of patient age, anticoagulation status, or whether bleeding has stopped.