How should I evaluate and manage a patient who presents with hematuria containing clots, including stabilization, diagnostic work‑up, and treatment of underlying causes?

Hematuria with Clots: Evaluation and Management

Hematuria with clots represents gross hematuria and mandates urgent urologic evaluation with cystoscopy and upper tract imaging, regardless of whether bleeding is self-limited, because it carries a 30-40% risk of malignancy. 1, 2

Immediate Stabilization and Assessment

Hemodynamic Evaluation

• Assess vital signs immediately to determine if the patient is hemodynamically stable or in shock 1
• For patients with ongoing bleeding and hemodynamic instability, maintain systolic blood pressure 80-100 mmHg until major bleeding is controlled (in patients without brain injury) 1
• Target hemoglobin >7 g/dL during resuscitation and avoid fluid overload, which can exacerbate bleeding 1
• Obtain complete blood count, coagulation studies (PT/INR, aPTT), and type and screen 2

Bladder Management for Clot Retention

• If the patient has clot retention with inability to void or bladder distension, place a large-bore three-way Foley catheter (22-24 Fr) for continuous bladder irrigation 2
• Perform manual irrigation with normal saline to evacuate clots and prevent catheter obstruction 2
• Never attribute gross hematuria to anticoagulation alone—these medications may unmask underlying pathology but do not cause hematuria themselves, and full evaluation must proceed 1, 2

Diagnostic Work-Up

Confirm True Hematuria

• Verify visible blood in urine and exclude pseudohematuria (myoglobin, food dyes, medications) 2
• Obtain urinalysis with microscopy confirming ≥3 RBCs per high-power field 1, 2
• Examine urinary sediment for dysmorphic RBCs (>80%), red cell casts, and proteinuria to assess for glomerular disease 2, 3

Initial Laboratory Evaluation

• Serum creatinine and BUN to assess renal function 1, 2
• Urine culture before antibiotics if infection is suspected, but do not delay evaluation for culture results 2, 4
• Urine cytology in high-risk patients (age >60, smoking history >30 pack-years, occupational chemical exposure) 1, 2

Risk Stratification (AUA/SUFU 2025 Guidelines)

The presence of clots automatically places the patient in the high-risk category requiring complete evaluation 1:

High-risk features include:

• Any gross hematuria (including clots) 1
• Age ≥60 years (men) 1
• Smoking history >30 pack-years 1
• Occupational exposure to benzenes, aromatic amines, or other bladder carcinogens 1, 2
• Irritative voiding symptoms without infection 1

• 25 RBC/HPF on microscopy 1

Mandatory Imaging

Multiphasic CT urography is the preferred imaging modality and must include 1, 2:

• Unenhanced phase to detect calculi
• Nephrographic phase to evaluate renal parenchyma and detect renal masses
• Excretory phase to evaluate the urothelium of upper tracts, ureters, and bladder

Alternative imaging (if CT contraindicated due to renal insufficiency or contrast allergy) 1, 2:

• MR urography
• Renal ultrasound with retrograde pyelography (less optimal)

Mandatory Cystoscopy

• Flexible cystoscopy is mandatory for all patients with gross hematuria, regardless of age 1, 2
• Flexible cystoscopy is preferred over rigid cystoscopy because it causes less pain and has equivalent or superior diagnostic accuracy 1, 2
• Cystoscopy must visualize bladder mucosa, urethra, and ureteral orifices to exclude bladder cancer 2
• Do not defer cystoscopy based on imaging findings—bladder cancer is the most common malignancy in hematuria patients and requires direct visualization 1, 2

Distinguishing Glomerular from Urologic Sources

Glomerular Features (Require Nephrology Referral in Addition to Urologic Evaluation)

• Tea-colored or cola-colored urine 2
• Proteinuria >500 mg/24 hours (spot protein-to-creatinine ratio >0.5 g/g) 2
• >80% dysmorphic RBCs on phase-contrast microscopy 2, 3
• Red cell casts (pathognomonic for glomerular disease) 2, 3
• Elevated serum creatinine or declining renal function 1, 3

Critical point: The presence of glomerular features does not eliminate the need for complete urologic evaluation, as malignancy can coexist with medical renal disease 2

Treatment of Underlying Causes

Urologic Malignancy

• Bladder cancer is the most frequently diagnosed malignancy in hematuria cases 2
• Urgent urology referral for transurethral resection of bladder tumor (TURBT) if lesion identified 1
• Delays in diagnosis beyond 9 months are associated with 34% increased cancer-specific mortality 1

Urinary Tract Infection

• If urine culture is positive, treat with appropriate antibiotics and repeat urinalysis 6 weeks after treatment 3
• If hematuria persists after treating infection, proceed with full urologic evaluation—infection does not exclude malignancy 3

Urolithiasis

• CT urography will detect stones causing obstruction and bleeding 1, 2
• Management depends on stone size, location, and degree of obstruction 2

Coagulopathy or Anticoagulation

• Correct coagulopathy with appropriate reversal agents or blood products if bleeding is severe 1
• Do not discontinue anticoagulation without consulting the prescribing physician—hematuria on anticoagulation still requires full evaluation 1, 2

Follow-Up and Surveillance

If Initial Evaluation is Negative

• Repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring at each visit 1, 2
• After two consecutive negative annual urinalyses, no further testing is necessary 1

Immediate Re-Evaluation Warranted If:

• Recurrent gross hematuria 2
• Significant increase in microscopic hematuria 2
• New urologic symptoms (flank pain, dysuria, irritative voiding symptoms) 2
• Development of hypertension, proteinuria, or evidence of glomerular bleeding 2

Common Pitfalls to Avoid

• Never ignore gross hematuria, even if self-limited—30-40% malignancy risk mandates urgent evaluation 1, 2
• Never attribute hematuria to anticoagulation or antiplatelet therapy alone—these medications unmask underlying pathology requiring investigation 1, 2
• Never delay evaluation waiting for infection to clear—persistent hematuria after appropriate antibiotic therapy strongly suggests non-infectious etiology 2
• Never rely on imaging alone without cystoscopy—bladder cancer requires direct visualization and cannot be reliably excluded by CT 1, 2
• Never assume benign prostatic hyperplasia explains gross hematuria in men—BPH can cause hematuria but does not exclude concurrent malignancy 2
• Do not defer evaluation in elderly patients—hematuria can precede bladder cancer diagnosis by many years, making evaluation essential regardless of age 2