Hematuria
at the bedside
- airway, breathing, circulation; full vitals, cardiac monitor if bleeding heavily, IV access
- already catheterized → output over the last hours, tubing (kinked, clots in it), leakage around the catheter, suprapubic distension; recent insertion or traumatic manipulation
- can the patient void → suprapubic distension, or no urine with clots: clot retention
- is it blood → the dipstick reads hemoglobin and myoglobin too; microscopy confirms red cells
- look at the urine → clots, color, pain with it
- drug chart → anticoagulant or antiplatelet: which one, last dose
escalate now if
- hypotension, tachycardia, or a falling hemoglobin with visible bleeding → significant bleeding, urology now
- cannot void, distended painful bladder, passing clots, or a catheter that has stopped draining → clot retention, urology first
- hematuria with AKI, significant proteinuria, red cell casts, or features of systemic vasculitis → glomerular bleeding, urgent nephrology discussion; creatinine rising fast → same day
- fever or flank pain → infection is one possibility; a suspected infected obstruction needs urgent escalation and imaging, do not assume stone or pyelonephritis → dysuria
- anticoagulated → how heavy is the bleeding, which drug, last dose → coagulation profile
differentials
- painful → UTI, stones, catheter trauma or recent instrumentation, papillary necrosis
- painless, visible → bladder or upper-tract tumor until proven otherwise, prostate, anticoagulant unmasking a lesion
- glomerular → cola-colored urine, dysmorphic red cells or casts, protein, hypertension, edema; recent sore throat or skin infection; rash, joint pain or hemoptysis (vasculitis)
- timing in the stream → initial: urethra; terminal: bladder neck or prostate; throughout: bladder, upper tract or glomerular
- not blood → myoglobin (rhabdomyolysis), hemoglobin (hemolysis), beetroot, rifampicin, menstrual contamination
focused check
- bleeding → visible or microscopic, clots, how long, which part of the stream; catheterized: when it changed, output since
- symptoms → pain, fever, dysuria, LUTS, recent sore throat, rash, hemoptysis
- drug chart → anticoagulant or antiplatelet (which, last dose, INR; creatinine if a DOAC), cyclophosphamide, rifampicin
- history → stones, prostate disease, catheter days and any recent insertion or manipulation, trauma, pelvic radiation, smoking, kidney disease in the family
- exam → palpable bladder, flank tenderness, palpable kidneys, edema and BP, petechiae or bruising, DRE if prostate is suspected; volume status before any fluid decision
send now
- frank blood with clots → no microscopy needed before urgent management; CBC, RFT and coagulation now
- urine microscopy → for microscopic hematuria: ≥ 3 RBC/HPF confirms (AUA/SUFU 2025); dysmorphic cells or red cell casts: glomerular
- urine protein:creatinine → glomerular source suspected; culture → infection suspected
- CBC → hemoglobin and platelets; RFT → AKI → acute kidney injury
- coagulation → on anticoagulants or a bleeding tendency; group and save → substantial ongoing bleeding, falling hemoglobin, hemodynamic concern or a possible intervention, not every episode
- dipstick positive, no red cells → CK for rhabdomyolysis, hemolysis screen
imaging
- stones suspected → non-contrast CT KUB; trauma → CT with contrast
- suspected infected obstruction → fever or sepsis with flank pain or AKI: ultrasound or CT KUB tonight, with urology
- pregnant or renal impairment → ultrasound first
- uncomplicated visible hematuria → no urgent CT urography; cystoscopy and CT urography by urology, not tonight (CT KUB does not image the urothelium); obstruction, trauma, sepsis or significant bleeding may need urgent imaging for that reason
treat
clot retention
- urology urgently → while they come, assess patency and distension: palpate, bladder scan, check the tubing
- large-bore 3-way Foley 20–24 Fr by a trained clinician; the bore lets clots pass; a blocked 2-way catheter is exchanged, not forced
- gentle manual washout with sterile 0.9% saline by catheter-tip syringe, local protocol, never against resistance, until the effluent clears
- once draining → continuous bladder irrigation for ongoing bleeding or recurrent clots: it keeps the catheter patent and prevents re-accumulation, it does not clear retained clots
- persistent obstruction, or clots that will not wash out → urgent urology for cystoscopic evacuation
- true urine output → total drainage minus irrigant instilled; chart both volumes
- outflow blocked, inflow running → the bladder overdistends: stop the inflow, washout, call urology
significant bleeding
- active major hemorrhage → two large IV cannulas, crossmatch; red cells by physiology and ongoing loss, not the hemoglobin alone; shock → hypotension, massive hemorrhage
- stable, bleeding controlled → transfuse at hemoglobin < 7 g/dL, < 8 with cardiovascular disease; one unit, then recheck → hemoglobin drop
- platelets → keep > 50 ×10⁹/L while bleeding
- anticoagulant → bleeding severity, indication, drug and last dose; withhold during major bleeding; life-threatening or uncontrolled major bleeding → discuss reversal urgently with hematology and the treating team: warfarin PCC 25–50 units/kg IV + vitamin K 10 mg IV; dabigatran idarucizumab 5 g IV; apixaban or rivaroxaban 4F-PCC 25–50 units/kg IV; document the restart plan with the treating team → coagulation profile
glomerular bleeding
- hematuria with AKI, significant proteinuria, red cell casts, or systemic vasculitis features (rash, joint pain, hemoptysis) → urgent nephrology discussion; rapidly progressive renal dysfunction → the same day, not the next clinic
- glomerular features do not always remove the need for urological evaluation; isolated microscopic hematuria without AKI, proteinuria or casts is not a nephrology call overnight: document, hand to the treating team
- creatinine rising → acute kidney injury
everything else
- fluids → assess volume status first; oral intake or IV fluids only when clinically indicated, not routinely to keep the urine flowing (heart failure, CKD, overload); fluids do not treat clot retention → IV fluids
- analgesia → paracetamol 1 g PO/IV q6h; no NSAIDs while bleeding or in renal impairment
- infection → cultures, then dysuria, empiric antibiotics (complicated UTI row); an infected obstruction needs drainage with urology, not antibiotics alone; hematuria that persists after treatment still needs a workup
- catheter trauma → bleeding after insertion or manipulation: confirm the balloon is in the bladder (drains freely, no leak), secure it, watch the output; stops draining → clot retention
- on an anticoagulant, minor bleeding → the drug does not explain the bleeding; same workup; continue it unless the bleeding is significant, any hold agreed with the treating team
- painless visible hematuria that settles → urology referral by the treating team for cystoscopy and CT urography
reassess
- when → 30 to 60 min after any catheter work or transfusion, then each round
- urine → clearing or darkening, new clots, catheter draining freely, leakage around it; on CBI, outflow volume against irrigant instilled
- patient → suprapubic pain or distension, heart rate and BP; repeat hemoglobin if bleeding continues or observations change
- hand over → hemoglobin trend, catheter and irrigation status (irrigant in, drainage out), anticoagulant held and the restart plan, urology or nephrology plan, escalation trigger
evidence
| source | type |
|---|---|
| AUA/SUFU 2020, amended 2025 · Microhematuria ↗︎ | international guideline |
| NSW ACI 2026 · Bladder irrigation toolkit ↗︎ | clinical toolkit |
| ACC 2020 · Expert consensus pathway, bleeding on oral anticoagulants ↗︎ | expert consensus |
Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.
free the on-call checklist covers the whole shift on one printable page.
studying for the IM exam? the IM Rapid Review covers this in the same format. see the sample chapter.
reviewed Jul 2026updated Oct 2026file complaint/hematuria