Hematuria
ABCs
- vitals → hypotension, tachycardia
- volume status: pallor, capillary refill, JVP
- can the patient void? suprapubic distension or inability to pass urine → clot retention
- confirm true hematuria: dipstick detects hemoglobin, not RBCs (myoglobinuria and hemoglobinuria also test positive); send microscopy to confirm RBCs
unstable or clot retention
- hemodynamic instability or falling Hb with gross hematuria → resuscitate (fluids ± blood), crossmatch, urgent Urology
- clot retention: unable to void, suprapubic distension, pain → urologic emergency: 3-way Foley + irrigation
- AKI with hematuria → assess for obstruction (bilateral clot, stones) and glomerular disease
don’t miss
- painless visible hematuria → malignancy until proven otherwise (age, smoking, occupational exposures)
- glomerular clues: proteinuria, dysmorphic RBCs or red cell casts, HTN, edema, rising creatinine → Nephrology, not Urology
- fever + hematuria → pyelonephritis, infected stone, endocarditis (at-risk)
- anticoagulation: hematuria on anticoagulants still requires evaluation; the drug may unmask pathology
- recent urological instrumentation or trauma
escalation
- hemodynamic instability or persistent bleeding despite irrigation → Urology (may need theatre)
- clot retention requiring CBI
- AKI or suspected glomerulonephritis → Nephrology
- suspected malignancy → Urology for cystoscopy ± imaging
- sepsis or hemodynamic instability → shock management
HPI & examination
- visible vs non-visible
- visible (gross): red, pink, or cola-coloured urine
- non-visible (microscopic): dipstick or urinalysis
- painful vs painless
- painful → UTI, stones, trauma, papillary necrosis
- painless → BPH, malignancy, glomerular disease, coagulopathy
- timing in stream
- initial → urethral source
- terminal → bladder neck or prostatic
- throughout → bladder, upper tract, or glomerular
- glomerular history
- recent sore throat or skin infection (post-streptococcal GN, IgA nephropathy)
- facial/periorbital edema, foamy urine, HTN
- systemic: rash, joint pain, hemoptysis (vasculitis)
- family history of renal disease (Alport, PKD)
- urological history
- prior stones, BPH, GU malignancy, instrumentation, catheterization
- LUTS, dysuria, urgency, frequency
- malignancy risk factors
- age (men ≥ 40, women ≥ 50 intermediate; ≥ 60 high risk), smoking ≥ 10 pack-years, occupational exposure (dyes, rubber, chemicals)
- prior pelvic radiation, cyclophosphamide
- other
- anticoagulants/antiplatelets: agent, indication, last INR
- trauma: flank, abdominal, pelvic; exercise-related hematuria usually resolves within 48-72 h
- menstruation, vaginal bleeding → contamination; repeat clean-catch or catheter specimen
- red urine mimics: beetroot, rifampicin, phenazopyridine, concentrated urate
- examination
- flank tenderness → stones, pyelonephritis, renal mass
- suprapubic distension → clot retention
- palpable kidneys → PKD, mass
- edema, HTN → glomerular disease
- coagulopathy signs: petechiae, ecchymoses
- DRE if BPH or prostate malignancy suspected
workup
- urine microscopy: confirm ≥ 3 RBCs/HPF. Dysmorphic RBCs or red cell casts → glomerular source
- dipstick positive, no RBCs on microscopy → myoglobinuria or hemoglobinuria (ABCs above)
- urine culture → if infection suspected
- uPCR → if glomerular source suspected
- CBC → Hb, platelet count
- RFT, creatinine → baseline renal function, AKI
- coagulation profile → if on anticoagulants or bleeding diathesis
- group and screen → if significant visible hematuria or hemodynamic concern
imaging
- not every hematuria patient needs immediate imaging
- stones suspected → CT KUB (non-contrast)
- high risk (visible hematuria, age ≥ 60, ≥ 10 pack-year smoking, other AUA risk factors) → Urology for cystoscopy + CT urography (CT KUB alone does not image urothelium)
- trauma → CT abdomen/pelvis with contrast
- pregnancy → renal ultrasound (avoid CT)
- renal impairment → ultrasound first if contrast is a concern
- low-risk non-visible hematuria (younger, non-smoker, no risk factors) → repeat urinalysis in 6 weeks before full imaging
- urine cytology no longer recommended as routine initial workup
management
clot retention
- 3-way Foley catheter (20-24 Fr): large bore allows clot passage
- manual irrigation with NS via catheter-tip syringe until effluent clears
- manual irrigation fails → continuous bladder irrigation (CBI)
- CBI fails or ongoing significant bleeding → Urology for cystoscopy and clot evacuation in theatre
- hydration: IV or PO, maintain urine output to reduce clot formation
- supportive targets
- Hb ≥ 7 g/dL (≥ 8 if CAD or hemodynamically significant bleeding)
- platelets > 50 ×10⁹/L if actively bleeding
- correct coagulopathy: reverse anticoagulation if life-threatening bleeding (risk-benefit discussion with prescribing team)
- anticoagulants: hematuria is not “explained” by anticoagulation; the drug may unmask a lesion (malignancy, stone, GN). Evaluate as for any hematuria; hold or reverse only for clinically significant bleeding, not routinely
- infection → empiric antibiotics by source; if hematuria persists after UTI treatment, follow-up evaluation still needed
- glomerular hematuria: proteinuria, dysmorphic RBCs, casts, rising creatinine, or systemic features → Nephrology referral, not Urology cystoscopy; declining renal function → AKI
- analgesia: paracetamol 1 g PO/IV q6h; avoid NSAIDs in active bleeding (antiplatelet effect) and renal impairment
disposition
- admit: hemodynamic instability, clot retention, significant Hb drop, AKI, sepsis, need for CBI or theatre
- urgent outpatient: visible hematuria that has settled + high-risk features → urgent Urology referral
- routine outpatient: stable non-visible hematuria, no high-risk features → repeat urinalysis, renal function, Urology or Nephrology based on likely source
evidence
| source | type |
|---|---|
| AUA 2020 · Microhematuria ↗︎ | international guideline |
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 Sep 2026file complaint/hematuria