What is the emergency room treatment for gross hematuria (frank hematuria)?

From the Guidelines

Emergency room treatment of frank hematuria should prioritize identifying and addressing the underlying cause while stabilizing the patient, with an emphasis on urgent urological consultation for patients with hemodynamic instability, clot retention, or suspected upper urinary tract bleeding. Initial management includes obtaining vital signs, assessing hemodynamic stability, and placing large-bore IV access if the patient shows signs of significant blood loss. A complete blood count, basic metabolic panel, coagulation studies, and urinalysis should be ordered immediately, as recommended by the ACR Appropriateness Criteria for hematuria 1. Patients on anticoagulants may need reversal agents if bleeding is severe - for warfarin, vitamin K or prothrombin complex concentrate; for DOACs, specific reversal agents like idarucizumab for dabigatran or andexanet alfa for factor Xa inhibitors.

Key Considerations

• Continuous bladder irrigation with a three-way Foley catheter using normal saline may be necessary for clot evacuation, typically at rates of 150-200 mL/hour.
• If large clots are present causing urinary retention, manual irrigation with a Toomey syringe may be required.
• Blood transfusion should be considered for hemodynamically unstable patients or those with significant drops in hemoglobin.
• Pain control with medications like acetaminophen or opioids may be needed, while avoiding NSAIDs which can worsen bleeding.
• The underlying etiology must be determined, as frank hematuria can result from infection, trauma, stones, malignancy, or vascular abnormalities, each requiring specific treatment approaches.

According to the AUA/SUFU guideline on adult neurogenic lower urinary tract dysfunction, patients with concomitant hematuria, recurrent urinary tract infections, or suspected anatomic anomaly should undergo cystoscopy 1. This is particularly important for patients with painless gross hematuria, who require upper tract imaging and a cystoscopy to rule out malignancy or other underlying conditions. Urgent urological consultation is essential to guide further management and treatment, and to determine the need for additional diagnostic tests or interventions.

From the Research

Emergency Room Treatment of Frank Hematuria

• The treatment of frank hematuria in the emergency room involves a thorough evaluation to determine the cause and assess the risk of malignancy 2.
• The initial assessment includes a full blood count, urea and electrolyte levels, midstream urine dipstick, beta human chorionic gonadotrophin, and formal microscopy, culture and sensitivities 2.
• The management of macroscopic haematuria aims at RESP--Resuscitation, Ensuring, Safe and Prompt, and indications for admission include clot retention, cardiovascular instability, uncontrolled pain, sepsis, acute renal failure, coagulopathy, severe comorbidity, heavy haematuria or social restrictions 2.
• Discharged patients should drink plenty of clear fluids and return for further medical attention if they experience clot retention, worsening haematuria despite adequate fluid intake, uncontrolled pain or fever, or inability to cope at home 2.

Diagnostic Approach

• The diagnostic approach to hematuria involves answering three key questions: (1) Is it really hematuria? (2) Should this patient with hematuria be worked up, and if so, how? (3) Should this patient with hematuria be referred, and if so, to which specialty? 3.
• Hematuria is classified as either gross or microscopic, and the risk of malignancy with gross hematuria is greater than 10%, prompting a prompt urologic referral 4.
• Microscopic hematuria most commonly has benign causes, such as urinary tract infection, benign prostatic hyperplasia, and urinary calculi, but if no benign cause is found, the work-up includes laboratory tests to rule out intrinsic renal disease, imaging of the urinary tract, and referral to nephrology and urology subspecialists 4.

Treatment and Follow-up

• The treatment of hematuria depends on the underlying cause, and patients with macroscopic haematuria may require transfusions, especially if they are hemodynamically unstable 5.
• Follow-up by a urological team should be promptly arranged, ideally within the 2-week cancer referral target, to further evaluate and manage the patient 2.
• Patients with hematuria should be monitored for signs of complications, such as clot retention, worsening hematuria, or uncontrolled pain, and should return for further medical attention if they experience any of these symptoms 2.