Medications for Treating Hematuria in Adults
The treatment of hematuria in adults is fundamentally cause-directed rather than symptom-directed—there is no medication that "treats hematuria" itself; instead, you must identify and treat the underlying etiology. 1, 2
Core Principle: Diagnosis Before Treatment
Hematuria is a symptom, not a disease, and requires complete diagnostic evaluation before any therapeutic intervention. 1, 2 The appropriate medication depends entirely on the underlying cause identified through systematic work-up. 1, 3
Step 1: Confirm True Hematuria
- Obtain microscopic urinalysis showing ≥3 RBCs per high-power field on a properly collected clean-catch specimen before initiating any work-up or treatment. 1, 2
- Dipstick testing alone has only 65–99% specificity and can produce false positives from myoglobin, hemoglobin, or menstrual contamination. 1
Step 2: Identify the Underlying Cause
A. Urinary Tract Infection (UTI)
Medications:
- Nitrofurantoin, fosfomycin, or trimethoprim-sulfamethoxazole for uncomplicated lower UTI (if local resistance <20%). 2
- Fluoroquinolone or ceftriaxone for suspected pyelonephritis. 2
Critical caveat: Obtain urine culture before starting antibiotics. 1, 2 If hematuria persists 6 weeks after completing treatment, proceed with full urologic evaluation (cystoscopy + CT urography) because infection does not exclude concurrent malignancy. 1, 2
B. Urolithiasis (Kidney/Ureteral Stones)
Medications:
- NSAIDs (e.g., ketorolac, ibuprofen) for acute pain control. 3
- Alpha-blockers (e.g., tamsulosin 0.4 mg daily) to facilitate stone passage for distal ureteral stones <10 mm. 3
- Antiemetics (e.g., ondansetron) if nausea/vomiting present. 3
Diagnostic confirmation: Unenhanced CT is gold standard for detecting stones. 1, 4
C. Benign Prostatic Hyperplasia (BPH)
Medications:
- Alpha-blockers (e.g., tamsulosin, alfuzosin) to reduce bladder outlet obstruction. 1, 3
- 5-alpha reductase inhibitors (e.g., finasteride, dutasteride) for prostate volume reduction in men with large prostates (>30 g). 3
Critical pitfall: Gross hematuria from BPH must be proven to be of prostatic origin through appropriate evaluation—never assume BPH is the cause without excluding malignancy via cystoscopy. 1
D. Glomerulonephritis (Glomerular Bleeding)
Indications for nephrology referral:
- Dysmorphic RBCs >80% or red cell casts on microscopy. 1, 2
- Protein-to-creatinine ratio >0.5 g/g (or >500 mg/24 hours). 1, 2
- Elevated serum creatinine or declining renal function. 1, 2
- Hypertension accompanying hematuria and proteinuria. 1, 2
Medications (nephrology-directed):
- ACE inhibitors or ARBs for proteinuria reduction and blood pressure control in chronic kidney disease. 1
- Corticosteroids for specific glomerulonephritides (e.g., IgA nephropathy, lupus nephritis) as determined by renal biopsy. 1
- Immunosuppressants (e.g., cyclophosphamide, mycophenolate) for ANCA-associated vasculitis or severe lupus nephritis. 1
E. Interstitial Cystitis (IC) with Hematuria
Medications (after excluding malignancy via cystoscopy):
- Pentosan polysulfate sodium (Elmiron) 100 mg three times daily as first-line oral therapy for IC without Hunner lesions. 5
- Amitriptyline 25–75 mg at bedtime for pain modulation and bladder stabilization. 5
- Intravesical dimethyl sulfoxide (DMSO) instillations for refractory cases. 5
Critical requirement: Cystoscopy is mandatory to identify Hunner lesions (which require fulguration/resection) and to exclude bladder cancer. 5
F. Anticoagulation-Related Hematuria
Management principle: Anticoagulants and antiplatelet agents do not cause hematuria—they may only unmask underlying pathology. 1, 2
Action required:
- Do not discontinue anticoagulation without consulting the prescribing clinician. 1
- Proceed with full urologic evaluation (cystoscopy + CT urography) regardless of anticoagulation status. 1, 2
- If severe bleeding occurs, correct coagulopathy with appropriate reversal agents or blood products only after urologic consultation. 1
Step 3: Risk Stratification for Malignancy
High-risk features requiring urgent urologic evaluation (cystoscopy + CT urography):
- Age ≥60 years (both men and women). 1, 2
- Smoking history >30 pack-years. 1, 2
- Any history of gross hematuria (even if self-limited). 1, 2
- Occupational exposure to benzenes or aromatic amines. 1, 2
- Irritative voiding symptoms without documented infection. 1, 2
- Microscopic hematuria >25 RBCs/HPF. 1
Gross hematuria carries a 30–40% risk of malignancy and requires urgent urologic referral within 24–48 hours, even if bleeding is self-limited. 1, 2
Common Pitfalls to Avoid
- Never attribute hematuria to anticoagulation alone—full evaluation is mandatory. 1, 2
- Never ignore gross hematuria, even if transient—30–40% malignancy risk. 1, 2
- Never skip cystoscopy in patients ≥40 years with confirmed microscopic hematuria—bladder cancer cannot be excluded by imaging alone. 1, 2
- Never treat empirically with antibiotics without urine culture confirmation if infection is suspected. 1, 2
- Never delay urologic evaluation while treating a UTI in patients >35 years—age alone is a sufficient risk factor for full work-up. 1, 2
Follow-Up Protocol (If Initial Work-Up 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, further testing is unnecessary. 1
- Immediate re-evaluation is warranted if gross hematuria develops, microscopic hematuria markedly increases, new urologic symptoms appear, or hypertension/proteinuria/glomerular bleeding emerges. 1, 2