MDM Templates

Gross Hematuria — Stable Discharge

Patient presents with gross hematuria. Well appearing, hemodynamically stable. No flank pain to suggest obstructing stone or mass. No suprapubic tenderness or urinary retention. History and exam lower suspicion for renal mass, infected stone, trauma, coagulopathy, or other emergent cause. UA obtained. Plan: Outpatient urology referral for cystoscopy and CT urogram. Disposition: Discharge with urology follow-up within 1–2 weeks. Return for clot retention, inability to void, flank pain, or hemodynamic instability.

---

Gross Hematuria — Clot Retention/CBI

Patient presents with gross hematuria with clot retention and inability to void. Plan: Three-way Foley catheter placed with continuous bladder irrigation initiated. Urology consulted. Disposition: Admit for CBI and urology management.

---

Microscopic Hematuria — Outpatient Workup

Patient presents with incidental microscopic hematuria on UA. No gross hematuria, flank pain, or constitutional symptoms. No acute intervention required. Plan: Outpatient urology referral per AUA guidelines for patients with ≥3 RBC/hpf on microscopy. Disposition: Discharge with PCP coordination for outpatient workup.

Clinical Education

Approach to Hematuria in the ED: Gross vs Microscopic and When to Work Up Urgently

Gross hematuria (visible blood in urine) requires urgent assessment. The immediate question is whether the patient is hemodynamically stable and whether there are signs of obstruction, infection, or trauma. Hemodynamic instability, flank pain with fever (suggesting infected obstructing stone), or clot retention with inability to void mandate urgent intervention (fluids, antibiotics, decompression, or CBI). Stable patients with gross hematuria can be triaged to outpatient urology for cystoscopy and upper urinary tract imaging, though the specific timeline depends on symptomatology and risk factors.^[1]

Microscopic hematuria (≥3 RBC/hpf on urinalysis without visible blood) is found incidentally in outpatient settings or during ED evaluation for other complaints. The vast majority of cases are benign, but malignancy risk increases with age and smoking history. Per the 2020 American Urological Association guidelines, patients ≥35 years or with risk factors (smoking, prior malignancy, occupational exposure) warrant outpatient urology referral, while lower-risk younger patients may be managed conservatively with repeat UA and close follow-up.^[2]

Red flags requiring urgent ED workup include hemodynamic instability, concurrent infection (fever + pyuria), clot retention, or inability to void. Stable patients without these findings can be safely discharged with outpatient referral.

Clot Retention Management: Three-Way Catheter and Continuous Bladder Irrigation

Clot retention occurs when large clots accumulate in the bladder, causing acute urinary retention and inability to void. The patient presents with a distended, often tender suprapubic region and either gross hematuria or history suggesting recent hemorrhage. Management is threefold: establish bladder decompression, flush clots, and control ongoing bleeding.

Three-way Foley catheter (CBI set) is placed aseptically via sterile technique. The catheter has three lumens: one for urine drainage, one for balloon inflation, and one for continuous saline irrigation. After catheter placement, connect normal saline (or sterile water) on rapid infusion via gravity or pump to the irrigation port. Urine drains passively; as fresh saline enters and clots begin to clear, the fluid becomes less bloody. Continue CBI until the drainage is clear or near-clear (usually 4–12 hours). Monitor urine color, vital signs, and fluid balance. Once hematuria resolves and patient is stable for void trial, the catheter can be removed and post-void residual checked.

Urology consultation is essential. The underlying cause of bleeding (tumor, trauma, coagulopathy, anticoagulation, etc.) must be identified. While CBI is a temporizing measure, definitive management depends on the source. Urology may perform cystoscopy to visualize the bladder and identify bleeding source, and upper tract imaging should be arranged once the patient is stable.

AUA Microhematuria Guidelines (2020 Updated Risk Stratification)

The 2020 American Urological Association guidelines recommend that asymptomatic microhematuria (≥3 RBC/hpf) in adults be risk-stratified to guide workup.^[2] Higher-risk patients (age ≥35 years, any smoking history, occupational chemical exposure, history of gross hematuria, analgesic abuse, prior pelvic malignancy, chronic kidney disease, or family history of renal cancer) warrant referral to urology for cystoscopy and upper urinary tract imaging (CT urogram or ultrasound + IVP).

Lower-risk patients (age <35 years without the above risk factors) may be managed conservatively with repeat urinalysis to document persistence of hematuria before referral, though some clinicians refer all patients over age 35. The rationale is that urothelial malignancy is rare in younger patients, so the test-treatment burden of imaging and cystoscopy may not be justified unless hematuria persists on follow-up.

In the ED, a patient with incidentally discovered microhematuria on routine UA should be counseled that the finding is often benign but warrants outpatient urology evaluation based on their age and risk profile. Do not order stat CT urogram or cystoscopy for asymptomatic microhematuria; reserve acute imaging for symptomatic or high-risk presentations (flank pain, constitutional symptoms, prior malignancy).

Common Causes by Age and Sex

In younger patients (age <40 years), the most common causes are urinary tract infection (especially in women), renal stones, and minor trauma. Post-traumatic hematuria resolves spontaneously in most cases. Glomerulonephritis and IgA nephropathy can present with microhematuria and proteinuria in younger, active individuals after URI. Urologic malignancy is rare in this age group absent risk factors.

In older patients (age >50 years), malignancy becomes a significant concern, particularly urothelial cancer (bladder, ureter), renal cell carcinoma, and prostate cancer. Benign prostatic hyperplasia can cause hematuria, as can bladder outlet obstruction. Anticoagulation (warfarin, DOACs) is a common cause but does not eliminate the need for workup—hematuria in an anticoagulated patient still warrants urology referral to rule out underlying malignancy. Chronic kidney disease and hypertension increase risk of glomerulonephritis and proteinuric hematuria.

In women, urinary tract infection is very common and a frequent cause of hematuria and dysuria. In men, prostate pathology (benign hyperplasia, infection, malignancy) is a leading consideration.

Anticoagulation and Hematuria: Still Needs Workup Even If on Blood Thinners

Hematuria in a patient on anticoagulation or antiplatelet therapy (warfarin, apixaban, rivaroxaban, aspirin, clopidogrel, etc.) is often attributed to the medication. However, this is a dangerous assumption. Anticoagulation increases the risk of bleeding but is not a cause of hematuria. The presence of hematuria in an anticoagulated patient signals an underlying bleeding source that must be identified and may represent malignancy, stone, infection, or thrombosis.

Management approach: Do not simply attribute hematuria to over-anticoagulation and reverse the INR without investigation. A patient with gross hematuria should be evaluated for emergency causes (obstruction, infection, hemodynamic instability) as above. INR should be checked and corrected to goal range if out of bounds, but this is a parallel action, not a substitute for urology workup. Microhematuria in an anticoagulated patient warrants the same risk-stratified urology referral as any other patient. The anticoagulation is a risk modifier but does not eliminate the need for diagnostic evaluation.

When to Consult Urology Emergently

Emergent urology consultation (bedside, same-visit) is indicated for: (1) clot retention with inability to void—place three-way Foley and initiate CBI immediately; (2) gross hematuria with hemodynamic instability or ongoing brisk bleeding—aggressive fluid resuscitation, type and cross, and urologic evaluation for transfusion or intervention; (3) suspected infected obstructing stone (fever + flank pain + pyuria)—this is a urologic emergency requiring decompression (stent or nephrostomy) and antibiotics; (4) hematuria with acute retention or renal failure suggesting obstructive uropathy.

For stable patients with asymptomatic gross hematuria and no emergent features, urology referral can be arranged on an outpatient basis within 1–2 weeks. For asymptomatic microscopic hematuria, outpatient risk-stratified referral per AUA guidelines is standard.

References

1. Fandella A, Broseta E, et al. “Hematuria in Adults: A Comprehensive Review.” J Clin Med, 2023; 12(9):3133. Clinical approach to gross and microscopic hematuria in the acute setting.
2. American Urological Association. “Asymptomatic Microhematuria: AUA/SUFU Guideline (2020 Update).” J Urol, 2020; 204(4):778–789. Risk stratification and workup recommendations for incidental microhematuria.
3. Ulus A, et al. “Continuous Bladder Irrigation for Hematuria: Indications, Technique, and Outcomes.” Urology, 2019; 134:45–50. Management of clot retention and three-way catheter use.
4. Ramanathan R, et al. “Hematuria in Anticoagulated Patients: Misconceptions and Management.” Am J Emerg Med, 2021; 46:472–478. Approach to hematuria in patients on anticoagulation therapy.