Management of acute gross hematuria in adults

INTRODUCTION — Gross (macroscopic) hematuria is not acutely dangerous in most cases but can be a manifestation of life-threatening pathology in certain circumstances. As such, patients with gross hematuria should be evaluated and managed in a systematic fashion. Isolated hematuria rarely represents a true emergency unless non-glomerular hematuria is so brisk that it results in significant or symptomatic anemia or clots obstruct the ureter(s) or bladder outflow (ie, urethra). Regardless of the severity of bleeding or the underlying cause, the appearance of gross hematuria is often distressing to patients and caregivers. Every adult with gross hematuria, whether a single or multiple episodes, and no evidence of glomerular disease, infection, or urethral trauma (eg, post-catheter insertion) ultimately requires urologic evaluation, which will include cystoscopy and cross-sectional imaging of the kidneys and ureters.

This topic discusses the management of atraumatic gross hematuria in adults (algorithm 1). The following are discussed in separate topics:

●Etiology and evaluation of gross hematuria in adults and children (see "Etiology and evaluation of hematuria in adults" and "Evaluation of gross hematuria in children")

●Evaluation and management of acute urinary retention (see "Acute urinary retention")

●Hematuria from pelvic or renal trauma (see "Pelvic trauma: Initial evaluation and management" and "Blunt genitourinary trauma: Initial evaluation and management" and "Management of blunt and penetrating renal trauma")

●Urinary system malignancies (see "Overview of the initial approach and management of urothelial bladder cancer" and "Non-urothelial bladder cancer")

●Placement and complications of urinary bladder catheters (see "Placement and management of urinary bladder catheters in adults" and "Complications of urinary bladder catheters and preventive strategies")

INITIAL EVALUATION AND MANAGEMENT — An overview of management is provided in the algorithm (algorithm 1).

Confirm hematuria — A patient with suspected gross hematuria (ie, presence of red or brown urine without clots) should have hematuria confirmed by microscopic analysis of a fresh, centrifuged urine specimen to exclude hematuria mimics (algorithm 2 and figure 1). In a male patient, the presence of clots confirms hematuria (clots can be from menstruation in a female patient). Glomerular bleeding does not form clots or cause bladder outflow obstruction (table 1). The diagnosis of gross hematuria is discussed separately. (See "Etiology and evaluation of hematuria in adults", section on 'Gross hematuria' and "Etiology and evaluation of hematuria in adults", section on 'Initial evaluation'.)

Assess for anemia or shock — In a patient with ongoing or a recent history of gross hematuria, we assess for signs and symptoms of clinically significant anemia, such as tachycardia, pallor, hypotension, orthostasis, dyspnea, chest pain, and lightheadedness. Symptomatic blood loss is typically secondary to chronic bleeding from a urinary system malignancy, radiation cystitis, benign prostatic hypertrophy, or a renal arteriovenous malformation. It is seldom caused by an acute process, such as a ureteroarterial fistula from ureteral stent erosion into an iliac artery. Management of clinically significant anemia typically requires the following:

●Establish intravenous (IV) access

●Obtain laboratory studies (complete blood count, serum chemistries, coagulation studies, and ABO/RhD typing)

●Administer blood products (eg, red blood cells, platelets) and/or anticoagulation reversal agents (eg, prothrombin complex concentrate) as indicated (see "Indications and hemoglobin thresholds for RBC transfusion in adults" and "Massive blood transfusion" and "Approach to the adult with a suspected bleeding disorder", section on 'Actively bleeding patient')

A patient with hypotension or signs of shock with gross hematuria from suspected cystitis or a ureteral stone (which are common causes of gross hematuria) should be evaluated for infection and/or sepsis since these rarely cause clinically significant blood loss. Evaluation and management typically include the following:

●Obtain urine and blood cultures and administer antibiotics to cover complicated urinary tract infection (table 2) (see "Kidney stones in adults: Diagnosis and acute management of suspected nephrolithiasis", section on 'Evaluation of suspected nephrolithiasis' and "Acute complicated urinary tract infection (including pyelonephritis) in adults and adolescents")

●Perform non-contrast computed tomography (CT) of the abdomen and pelvis or renal ultrasound to evaluate for an obstructing kidney stone (see "Kidney stones in adults: Diagnosis and acute management of suspected nephrolithiasis", section on 'Evaluation of suspected nephrolithiasis' and "Acute complicated urinary tract infection (including pyelonephritis) in adults and adolescents")

●An obstructing kidney stone, if present, may require urgent decompression of the collecting system with either a ureteral stent or percutaneous nephrostomy tube (see "Kidney stones in adults: Surgical management of kidney and ureteral stones", section on 'Indications and contraindications')

●Provide hemodynamic support with IV crystalloid and vasopressors (as needed) (see "Evaluation and management of suspected sepsis and septic shock in adults")

Assess for bladder outflow obstruction — Clots in the setting of gross hematuria often obstruct bladder outflow and cause acute urinary retention (AUR). A patient with AUR typically has considerable lower abdominal and/or suprapubic pain and may be in distress from pain and urinary urgency. Examination may reveal abdominal or suprapubic tenderness or firmness from a distended and palpable urinary bladder. (See "Acute urinary retention", section on 'Initial evaluation'.)

AUR can be diagnosed by measuring bladder volume with either a bladder scan or point-of-care ultrasound. A bladder volume ≥300 mL suggests AUR and warrants decompression with a urinary catheter. If the patient is in discomfort and unable to void (regardless of the estimated volume) or if a bladder scan and ultrasound are not available, a urinary catheter should be placed, and the initial volume of drainage used to establish the diagnosis of AUR. (See "Acute urinary retention", section on 'Prompt diagnosis of retention'.)

PATIENT WITH BLADDER OUTFLOW OBSTRUCTION — In a patient with acute urinary retention (AUR) from gross hematuria and blood clots, management focuses on relieving the urinary obstruction, removing existing clots, and preventing the formation of new clots. These steps represent distinct interventions that are often combined, which can lead to treatment failures or complications.

Place a urinary bladder catheter — Promptly placing a urinary bladder catheter is critical since AUR can be quite painful, distressing, and can result in acute kidney injury or bladder perforation. For a patient with AUR in the setting of gross hematuria, we place a large bore (22 Fr or greater) urethral catheter. The only absolute contraindication to the placement of a urethral catheter is the presence of urethral injury, which is typically associated with pelvic trauma. Relative contraindications are discussed separately. (See "Placement and management of urinary bladder catheters in adults", section on 'Contraindications'.)

Insertion of a urinary catheter is generally a safe procedure. In a patient with recent urologic surgery that may have affected the integrity of the urethra (eg, prostatectomy, urethroplasty, or neo-bladder), we recommend consulting a urologist before attempting placement.

In a male patient, we instill lidocaine 2 percent jelly ("Urojet") 5 to 30 mL directly into the urethra to decrease patient discomfort, dilate the urethra, and facilitate catheter placement.

Catheters with large lumens (≥ 20 Fr) permit more successful and effective manual clot irrigation. Smaller catheters can be used but have a higher likelihood of being obstructed by blood clots. Any catheter type can be placed for the initial bladder decompression and manual irrigation, but unless the catheter has three lumens, it will need to be replaced if continuous bladder irrigation (CBI) is required. Thus, the benefits of a catheter with less than three lumens (eg, larger lumen) have to be balanced against the increased patient discomfort and risk of local trauma and complications with repeated catheter placements or placement attempts. (See "Complications of urinary bladder catheters and preventive strategies", section on 'Urethral catheters'.)

The following factors impact our choice of the catheter we place for manual irrigation (see "Placement and management of urinary bladder catheters in adults", section on 'Specialized catheters'):

●Suspected clots in the bladder – We prefer a red rubber Robinson catheter since it does not have a balloon or outflow channel and has a larger lumen, permitting removal of larger clots. Most experts consider the red rubber catheter as ideal for hematuria irrigation, but other catheters may be used because of circumstances and available equipment.

●Desire to avoid repeat urethral catheterization – We prefer a triple-lumen (ie, three-way) catheter since this can also be used for CBI. Upon insertion, apply a catheter plug (or the sterile cap of a 60cc catheter tip syringe) to block the smaller irrigation port.

●Enlarged prostate – A Coudé (ie, bent) catheter may be helpful since it has a curved tip that facilitates placement.

The catheter placement procedure is described separately. (See "Placement and management of urinary bladder catheters in adults", section on 'Transurethral catheter placement'.)

Catheter insertion should be aborted during placement if significant resistance is encountered, the patient complains of pain, or new bleeding at the meatus develops. If the catheter is inserted to the flared portion (ie, hub) and no urine is obtained, an assistant can be asked to apply gentle pressure to the suprapubic region, which may initiate urine flow. Gentle irrigation through the end of the catheter using 10 to 20 mL sterile saline may displace a clot and also initiate urine flow. Do not inflate the balloon (if present) unless placement is confirmed by return of urine or point-of-care ultrasound. (See "Placement and management of urinary bladder catheters in adults", section on 'Troubleshooting urethral catheter placement'.)

Role of intravesicular tranexamic acid — Topical (intravesicular) tranexamic acid (TXA) may help control hematuria. A trial that included 50 patients with hematuria found that instilling TXA 500 mg into the bladder for 15 minutes prior to bladder irrigation decreased the volume of required irrigation fluid but did not affect degree of blood loss [1]. A retrospective before-and-after study that included 159 patients found that instilling TXA 1 gram into the bladder for 15 minutes prior to bladder irrigation was associated with shorter emergency department length of stay, duration of urinary catheter, and fewer return visits [2]. Although these findings are promising, further research is needed before we can recommend routine use of topical TXA for hematuria.

Perform manual irrigation — After the urinary catheter is placed, we perform manual irrigation to remove all existing clots from the bladder [3]. The steps are as follows:

●Confirm that the catheter is in the bladder (typically observing return of urine). Point-of-care-ultrasound may be used to confirm that the catheter is in the bladder and/or quantify the amount of clot prior to initiating the procedure. If using a three-way catheter, ensure the open side port is plugged.

●Obtain a 60 mL catheter tipped syringe and one to two liters of irrigation fluid (either sterile saline or sterile water).

●Using sterile technique, gently infuse 120 mL of irrigation fluid into the catheter.

●Via the catheter drainage port, infuse 60 mL of irrigation fluid and then withdraw 60 mL to extract clots. Dispose of clots and fluid. Refill the 60cc syringe with irrigation fluid and repeat this step.

●If unable to withdraw fluid, use a push-pull technique with the syringe plunger or instill another 60 mL of irrigation fluid to attempt to break up the clots.

●Continue this process until no further clots are withdrawn and the returned urine is slight pink or clear.

●We will continue irrigating with an additional liter to ensure complete clot removal. Other experts will skip this extra irrigation, but this may increase the risk of clots remaining in the bladder [4].

●Connect the catheter to a drainage bag.

Manual bladder irrigation successfully clears the urine and clots in most circumstances. In a patient without residual hematuria and clots following manual irrigation, further bladder irrigation is not required. Catheter care and further evaluation are discussed below. (See 'After-care and follow-up' below.)

Some clots may be refractory to standard irrigation techniques. We define a failure of manual irrigation as the continued presence of clots or frank blood after irrigation with at least one liter. However, evidence does not exist to support an exact volume of irrigation fluid to employ before deciding that manual irrigation has failed. In a patient with failed manual irrigation, we recommend consulting a urologist. They may recommend or place a specialized "hematuria catheter," perform manual irrigation or CBI, request bladder imaging to assess clot burden, request reversal of anticoagulation (if present and not contraindicated), consult interventional radiology, or perform cystoscopy for bladder irrigation and fulguration of bleeding points. (See 'Indications for emergency urology consultation' below.)

Bladder irrigation facilitates hemostasis by clearing clots, which prevent detrusor muscle contraction and compression of bleeding vessels [4].

Ongoing hematuria after manual irrigation — In a patient with ongoing hematuria (ie, urine that is darker than slight pink) after adequate manual irrigation, we suggest initiating CBI to prevent formation of additional clots that may obstruct bladder outflow.

The following supplies are needed for CBI:

●3-liter bags of sterile saline for irrigation (multiple 1-liter bags can be substituted)

●Cystoscopy/bladder irrigation Y-type tubing (standard cystoscopy or intravenous [IV] tubing can be substituted)

●Large volume urine collection bag

●Catheter plug

●Gloves, mask, and eye protection

CBI is performed as follows:

●Attach the urine drainage bag to the large port of the three-way catheter using Y-type tubing (which allows for two irrigant bags to be attached simultaneously), standard cystoscopy tubing, or IV tubing.

●Spike the irrigant fluid bag with the irrigation tubing and prime the tubing to remove all air and then close the flow regulator. If using Y-type tubing, attach the second bag to the irrigation set.

●Attach the tubing to the smaller port of the 3-way catheter, ensuring that it is not connected to the balloon port.

●Using the flow regulator on the cystoscopy/bladder irrigation tubing, start the flow of irrigant.

●Titrate the speed and volume of irrigation based on the degree of hematuria to achieve a light pink (eg, pink lemonade) to light red (eg, fruit punch) color. Higher volumes and speed are needed for severe bleeding.

●Replace irrigation fluid bags and empty drainage bag as needed.

●As the hematuria resolves, decrease the rate and volume of irrigant to achieve the desired color.

Patients undergoing CBI require careful monitoring. If a residual or newly formed clot obstructs the bladder catheter while irrigation fluid is infusing, the patient can rapidly develop painful and dangerous bladder distension, which increases the risk of bladder perforation [3]. In a patient who complains of pain, develops drainage around the catheter, or the urine collection bag stops filling, stop the irrigation fluid immediately and repeat manual irrigation as described above. (See 'Perform manual irrigation' above.)

Similar to manual irrigation, CBI can be stopped when the urine is slight pink or clear. Hematuria may resolve rapidly in some patients, while others may require prolonged irrigation, sometimes lasting days. Five liters or more of irrigation is often required [4].

For a patient who has required CBI, it is reasonable to contact urology to discuss the acute plan of care if the clinician has any questions, or to expedite further workup and arrange for prompt follow-up prior to discharge. Catheter care and further evaluation are discussed below. (See 'After-care and follow-up' below.)

PATIENT WITHOUT BLADDER OUTFLOW OBSTRUCTION — There is no specific management for the hemodynamically stable patient with gross hematuria who is able to urinate; management is targeted towards the underlying etiology of the hematuria (figure 1 and algorithm 3). Placement of a urinary bladder catheter is not required. Every adult with gross hematuria, whether a single or multiple episodes, ultimately requires further evaluation for the etiology. (See 'Follow-up for all patients with gross hematuria' below.)

Even though there is no specific management, some patients may need monitoring to ensure stability prior to discharge. (See 'Disposition' below.)

INDICATIONS FOR EMERGENCY UROLOGY CONSULTATION — The following are indications for emergency consultation with a urologist:

●Persistent blood loss that could lead to significant anemia or hemodynamic instability

●Inability to maintain urinary catheter drainage of the bladder (eg, catheter keeps "clotting off")

●Inability to catheterize the patient

●Inability to clear the bladder after prolonged (ie, > 1 liter) manual irrigation

●Acute kidney failure

●Sepsis due to a urinary source

●Recent urologic procedure or surgery (eg, prostate biopsy, cystoscopy, bladder or prostate surgery)

●Ambiguity of urinary catheter patency

●Persistent bladder spasms

●Persistent leakage around the catheter

DISPOSITION — Gross hematuria is typically managed in the outpatient setting. All of the following criteria are required for a patient to be discharged:

●If a urinary catheter was placed, it is patent (eg, draining urine) and the patient and/or caregivers are able to care for it

●If there is no urinary catheter, the patient is able to void

●Patient is not having recurrent episodes of bladder outflow obstruction

●Patient is hemodynamically stable

●Kidney function is at patient's baseline

●There are no signs of ongoing blood loss (eg, decreasing hematocrit)

●There is no concern for sepsis

●The patient can be seen urgently by a urologist (typically within one week)

●There is no further gross hematuria (pink-tinged urine is acceptable)

If the patient does not meet discharge criteria, they should be admitted or observed in the emergency department depending on local standards [5].

In a patient with anemia, borderline anemia, comorbidities impacted by anemia (eg, coronary artery disease), anticoagulation, or with large amounts of hematuria (red-wine color), we observe for changes in vital signs and perform serial blood tests (eg, hematocrit and hemoglobin) for a minimum of three to six hours to ensure stability.

AFTER-CARE AND FOLLOW-UP

Indwelling bladder catheter — If a urinary bladder catheter was placed, we typically leave it in place in case hematuria recurs. However, some patients may prefer to have the catheter removed with the understanding it will need to be replaced if hematuria and/or urinary retention recurs. General care of an indwelling bladder catheter is discussed in detail separately. (See "Placement and management of urinary bladder catheters in adults", section on 'Catheter care'.)

We do not routinely start prophylactic antibiotics for all patients with an indwelling catheter. Some urologists may recommend antibiotics for patients with recurrent infections, patients with risk factors (eg, immunocompromise), or patients who had extensive irrigation or procedural manipulation. (See "Placement and management of urinary bladder catheters in adults", section on 'Prophylactic antibiotics' and "Catheter-associated urinary tract infection in adults", section on 'Prevention'.)

We instruct the patient to seek immediate care if they develop acute urinary retention or persistent gross hematuria.

Any patient discharged with an indwelling catheter for hematuria requires follow-up with a urologist within 7 to 10 days.

Follow-up for all patients with gross hematuria — Every adult with gross hematuria, whether a single or multiple episodes, ultimately requires further evaluation for the etiology, which is summarized in the algorithm (algorithm 3). The evaluation may include microscopic urinalysis, imaging (CT or magnetic resonance urography), cystoscopy, and may also involve assessment of kidney function, ultrasound, and/or kidney biopsy [6,7]. Every adult with hematuria with clots requires urgent urology follow-up for cystoscopy. The timing of imaging depends on the acuity of the presentation and availability of follow-up care but can often be performed by the patient's primary care doctor or urologist. The evaluation is discussed in detail separately. (See "Etiology and evaluation of hematuria in adults", section on 'Initial evaluation'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Urinary catheters" and "Society guideline links: Bladder cancer".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Blood in the urine (hematuria) in adults (The Basics)")

●Beyond the Basics topic (see "Patient education: Blood in the urine (hematuria) in adults (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Initial evaluation and management – An overview of the management of atraumatic acute gross hematuria in adults is provided in the algorithm (algorithm 1). In a male patient, the presence of clots confirms hematuria (clots can be from menstruation in a female patient). A patient with suspected gross hematuria (ie, presence of red or brown urine) should have the hematuria confirmed by microscopic analysis of a fresh, centrifuged urine specimen to exclude hematuria mimics (algorithm 2 and figure 1). (See 'Confirm hematuria' above.)

Gross hematuria is not acutely dangerous in most cases, but patients should be evaluated for signs and symptoms of blood-loss anemia. Symptomatic blood loss is seldom caused by an acute process (eg, ureteroarterial fistula from ureteral stent erosion into an iliac artery) and more likely secondary to chronic blood loss from a urinary system malignancy, radiation cystitis, benign prostatic hypertrophy, or renal arteriovenous malformation. (See 'Assess for anemia or shock' above.)

●Assess for bladder outflow obstruction – Clots in the setting of gross hematuria often obstruct bladder outflow and result in acute urinary retention (AUR), which causes considerable pain and abdominal or suprapubic tenderness or firmness. A bladder volume ≥300 mL measured with either bladder scan or point-of-care ultrasound suggests AUR and warrants decompression with a urinary catheter. (See 'Assess for bladder outflow obstruction' above.)

●Patient with bladder outflow obstruction – We place a large bore (22 Fr or greater) urethral catheter. A red rubber catheter allows for evacuation of larger clots while a triple-lumen (ie, three-way) catheter does not need to be replaced if continuous bladder irrigation (CBI) is needed. (See 'Place a urinary bladder catheter' above.)

We next perform manual irrigation to remove all existing clots from the bladder. (See 'Perform manual irrigation' above.)

In a patient with ongoing hematuria after adequate manual irrigation (ie, urine that is darker than slight pink), we suggest CBI to prevent formation of new or additional clots that may obstruct bladder outflow (Grade 2C). (See 'Ongoing hematuria after manual irrigation' above.)

●Patient without bladder outflow obstruction – There is no specific management for the hemodynamically stable patient with gross hematuria who is able to urinate. Placement of a urinary bladder catheter is not required. (See 'Patient without bladder outflow obstruction' above.)

●Emergency urology consultation – Indications for emergency urology consultation include persistent blood loss that could lead to significant anemia or hemodynamic instability, inability to place a bladder catheter or to maintain urinary catheter drainage of the bladder, acute kidney failure, recent urologic procedure, inability to clear the bladder after prolonged manual irrigation, and others. (See 'Indications for emergency urology consultation' above.)

●Evaluation of etiology in all patients – Gross hematuria is typically managed in the outpatient setting. Every adult with gross hematuria, whether a single or multiple episodes, ultimately requires further evaluation for the etiology, which is summarized in the algorithm (algorithm 3). Every adult with hematuria with clots requires urgent urology follow-up for cystoscopy and imaging of the kidneys and ureters (eg, CT urography). (See 'Follow-up for all patients with gross hematuria' above.)