UROLOGY : CLINICAL UPDATES FROM THE PRACTICE
HEMATURIA WORK-UP AND GUIDELINE UPDATES AUTHORS Hangcheng Fu , MD , Sriharsha Talluri , MD ,& Murali Ankem , MD
Gross hematuria ( GH ) and microscopic hematuria ( MH ) are common in both the urologic and primary care setting . MH often does not require urgent or emergent evaluation . MH also has updated American Urological Association ( AUA ) 2020 guidelines to cover most clinical questions . However , GH is a much more complicated situation , which sometimes warrants hospital admission and can even represent a life-threatening situation .
The differential diagnosis of hematuria is broad , presenting as either MH or GH . Etiologies are categorized into malignant / non-malignant associated hematurias . Non-malignancy associated hematuria includes infection / inflammation of urinary tract , calculus disease , benign prostatic enlargement , trauma , medical renal disease and abnormal or dysfunctional anatomic findings .
When a patient presents with GH , hemodynamic status with immediate exam must be obtained . An extremely small proportion of patients with GH will have significant blood loss requiring transfusion . A prolonged time of uncontrolled hematuria , passing large amounts of clots , or concurrent anticoagulant use are risk factors for acute blood loss from GH . Urinary retention is a more common urgent situation associated with GH requiring expeditious catheter placement and manual irrigation . This retention is caused by large clots obstructing the bladder or urethra . Large Foley catheters such as 22 Fr Rusch catheter with or without continuous bladder irrigation ( CBI ) are often required to ensure drainage and irrigation of bladder . Of note , do not initiate CBI until the bladder has been cleared of all blood clots , otherwise these clots may lead to bladder perforation ( continuous irrigant entering but not able to exit the bladder due to a large clot ). Even if the patient is able to urinate , a bladder scan or post-void residual is required for every gross hematuria patient to ensure the bladder is empty .
After these two acute issues are addressed , obtain a detailed history and physical exam for differential diagnosis . All anticoagulation , anti-platelet therapy and NSAIDS should be stopped . Laboratory studies like urinalysis , urine culture , complete blood count ( CBC ) with differential , basic metabolic panel ( BMP ) and coagulation studies ( PT / INR ) should be ordered stat on presentation to evaluate the degree and causes of the hematuria . Urinary tract infection ( UTI ) is the most common reason for hematuria . Empiric antibiotics are required for UTIs with adjustments based on the urine culture results . CT Urogram ( 3 phase CTU ) is the image of choice recommended by AUA for gross hematuria . A CT Urogram is contraindicated with kidney dysfunction . A typical CT Urogram protocol has three phases that allow complete evaluation for the most common
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