Hematuria
ABCs
- check vital signs → assess for instability
unstable + gross hematuria
- resuscitate (fluids ± blood)
- cross-match / reserve PRBCs
- call urgent Urology consult
red flags
don’t miss
- painless gross hematuria → malignancy until proven otherwise
- clot retention: suprapubic distension, unable to void
- coagulopathy: petechiae, bruising, recent anticoagulation
HPI & examination
- history
- prior renal stones, urological disease, instrumentation
- recent anticoagulation, bleeding tendency
- LUTS / UTI symptoms
- painful vs painless
- painful → UTI, stones, trauma, papillary necrosis
- painless → BPH, malignancy, coagulopathy
- examination
- flank tenderness → stones / pyelonephritis
- suprapubic distension → clot retention
- signs of coagulopathy: petechiae, bruising
workup
- urine R/M → confirm RBCs > 3/HPF
- CBC → Hb drop
- coagulation profile for bleeding risk
- infection suspected → urine culture ± sediment
- stones suspected → CT KUB (preferred) or X-ray KUB
- malignancy suspected / high risk → urine cytology ± cystoscopy
management
- initial
- IV or PO hydration
- unable to void / retention → insert a Foley catheter
- visible clots / gross hematuria → 3-way Foley, start manual irrigation
- persistent clots → continuous bladder irrigation (CBI) by Urology
- supportive targets
- maintain Hb ≥ 7 g/dL (≥ 8 if CAD)
- platelets > 50 ×10⁹/L if actively bleeding
- medications
- analgesia: paracetamol 1 g PO/IV q6h; avoid NSAIDs in active bleeding (antiplatelet effect)
- antibiotics if UTI / prostatitis / pyelonephritis suspected
- anticoagulation: hold / adjust if actively bleeding (after risk–benefit discussion)
escalation
- hemodynamic instability
- persistent bleeding despite initial measures
- clot retention requiring CBI
- suspicion of malignancy → Urology / Nephrology input
studying for the IM exam? the IM Rapid Review covers this in the same format. see the sample chapter.
Last reviewed · May 2026