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HematuriaAPPROACH

RENAL AND URINARY · 19 SECTIONS

⚲

561 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Oliguria And Anuria Catheter Related Urinary Complaints Dialysis Patient Presentations Flank Pain And Renal Colic Concern Urinary Retention Hematuria Scrotal Pain

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx82

HPI overview

›Hematuria presentation framing

›Gross hematuria

›Microscopic hematuria

›First episode

›Recurrent

›Bleeding pattern

›Initial stream

›Terminal

›Total

›Clots

Onset

›Onset timing

›Sudden

›Gradual

›After trigger

›Temporal context

›After exercise

›After trauma

›After procedure

›During infection symptoms

Provocation/Palliation

›Triggers

›Exertion

›Recent sexual activity

›Recent instrumentation

›Recent anticoagulant change

›Modifiers

02Alarm Features/alarm32

Immediate life threats

›Life threatening hematuria pathways

›Clot retention with obstructive uropathy

›Hemorrhagic shock

›Sepsis from obstructed infected system

›Trauma with renal vascular injury

Vital sign danger thresholds

›Hemodynamic instability thresholds

›SBP under 90 mmHg

›HR over 120

›Shock index over 1

›Sepsis physiology thresholds

›Temperature 38.0 C or higher

›RR 22 or higher

›Altered mental status

High risk historical triggers

›High risk triggers

›Recent urinary tract instrumentation

›Known renal mass

›Known bladder tumor

›Recent major trauma

›High risk populations

›Solitary kidney

›Kidney transplant recipient

›Immunocompromised state

›Pregnancy

High risk exam findings

›High risk findings

03Medications/meds27

Bleeding and renal relevant agents

›Antithrombotics and anticoagulants

›Warfarin

›DOACs

›Heparins

›Antiplatelets

›Nephrotoxic exposures

›NSAIDs

›Aminoglycosides

›IV contrast within prior 72 hours

›Hemorrhagic cystitis associated therapies

›Cyclophosphamide

›Ifosfamide

›Pelvic radiation history

Recent medication changes

›Change timeline

›New start within 30 days

›Dose escalation within 30 days

›Missed doses

›Interactions that increase bleeding

›SSRIs and SNRIs

›Azole antifungals

›Macrolides

Contraindications to likely therapies

›Analgesic considerations

›NSAID avoidance in suspected glomerulonephritis or AKI

›Opioid cautions in older adults and renal impairment

›Contrast considerations

04Diet/diet11

Exposure patterns

›Hydration pattern

›Poor intake

›High fluid intake

›Recent vomiting or diarrhea

›Food and supplement discoloration

›Beets

›Rhubarb

›B vitamins

›Alcohol exposure

›Heavy recent use

›Withdrawal risk context

05Review of Systems/ros28

Gen constitutional

›Constitutional symptoms

›Fever

›Chills

›Night sweats

›Unintentional weight loss

›Urinary symptoms

›Dysuria

›Frequency

›Urgency

›Retention

›Stone symptoms

›Colicky flank pain

›Radiation to groin

Cardiorespiratory

›Anemia and ischemia symptoms

›Chest pain

›Dyspnea

›Palpitations

›Thromboembolic context

›Leg swelling

›Pleuritic pain

Skin and MSK

›Vasculitis and systemic disease clues

›Purpura

›Arthralgias

›Oral ulcers

06Collateral History and Family History/chafh15

Collateral sources

›Source reliability

›Patient report reliability

›Family or caregiver collateral

›EMS documentation

Family history

›Malignancy and inherited renal disease

›Urothelial cancer in first degree relative

›Kidney cancer in first degree relative

›Polycystic kidney disease

›Alport syndrome

›Stone disease

›Recurrent nephrolithiasis in family

›Cystinuria history

Household and exposure context

›Infectious exposures

›Sick contacts

›Recent travel with schistosomiasis exposure risk

07Risk Factors/rf30

Malignancy risk

›Urothelial malignancy risk factors

›Age 35 or older

›Smoking history

›Occupational aromatic amine exposure

›Prior pelvic radiation

›High risk clinical features

›Gross hematuria

›Persistent microscopic hematuria

Stone and obstruction risk

›Nephrolithiasis risks

›Prior stones

›Low fluid intake

›Hyperparathyroidism history

›Obstruction risks

›Benign prostatic hyperplasia

›Neurogenic bladder

Glomerular disease risk

›Immune and inflammatory risks

›Recent streptococcal infection

›SLE

›IgA vasculitis history

›Metabolic risks

›Diabetes mellitus (E11.9)

›Hypertension (I10)

Infection risk

›UTI and pyelonephritis risks

›Prior recurrent UTI

08Differential Diagnosis/ddx51

Life threatening

›Cannot miss diagnoses

›Obstructed infected collecting system

›Fever

›Flank pain

›Hydronephrosis

›Major genitourinary trauma

›Mechanism with deceleration or flank impact

›Gross hematuria

›Flank ecchymosis

›Urothelial malignancy (C67.9)

›Painless gross hematuria

›Smoking history

›Renal cell carcinoma (C64.9)

›Flank mass

›Weight loss

Common

›Common etiologies

›Urinary tract infection (N39.0)

›Dysuria

›Positive nitrites or leukocyte esterase

›Nephrolithiasis (N20.0)

›Colicky flank pain

›Microscopic hematuria

›Benign prostatic hyperplasia (N40.0)

›Weak stream

›Incomplete emptying

›Menstrual contamination

09Past Medical History/pmh21

Prior GU history

›Prior urologic conditions

›Prior hematuria workup results

›Prior cystoscopy results

›Prior CT urogram results

›Stones and infections

›Prior nephrolithiasis episodes

›Prior pyelonephritis

Chronic disease and special populations

›Renal and systemic disease

›Chronic kidney disease (N18.9)

›Polycystic kidney disease (Q61.3)

›Sickle cell disease (D57.1)

›Bleeding risk conditions

›Cirrhosis (K74.60)

›Known thrombocytopenia

Prior procedures and devices

›GU procedures

›TURP history

›Ureteral stent history

›Nephrostomy history

›Devices

›Indwelling urinary catheter

›Recent catheter change

10Physical Exam/exam33

General and vitals

›General appearance and perfusion

›Toxic appearance

›Pallor

›Diaphoresis

›Vital sign patterns

›Tachycardia

›Hypotension

›Fever

Abdomen and flank

›Abdominal exam cluster

›Suprapubic tenderness

›Suprapubic distension

›Peritonitis signs

›Flank exam cluster

›CVA tenderness

›Flank ecchymosis

GU and pelvic

›External GU inspection

›Meatal bleeding

›Scrotal or penile trauma signs

›Pelvic considerations

›Vaginal bleeding source possibility

›Cervical motion tenderness context

Skin and extremities

›Systemic disease clues

›Purpura

›Edema

11Lab Studies/labs28

Urinalysis and microscopy

›UA interpretation framework

›Dipstick heme positive with RBC on microscopy supports hematuria

›Dipstick heme positive with few RBC suggests hemoglobinuria or myoglobinuria

›Microscopy features

›Dysmorphic RBC suggests glomerular source

›RBC casts suggest glomerulonephritis

›Proteinuria degree supports glomerular process

Infection evaluation

›Infectious labs

›Urine culture

›CBC with differential

›Sepsis adjuncts if systemic features

›Serum lactate

›Blood cultures before antibiotics when feasible

Renal function and bleeding

›Renal and electrolyte labs

›Creatinine and eGFR baseline comparison

›Potassium and bicarbonate for AKI complications

›Hemostasis labs

›INR for warfarin exposure

›Platelet count

›Fibrinogen if massive bleeding concern

Rhabdomyolysis and hemolysis

›Pigment workup when heme positive with few RBC

›CK

›Hemolysis labs

›LDH

12Imaging/img35

Scoring Systems

›Risk stratification for microscopic hematuria workup

›Malignancy risk tiering per urology guideline local protocol dependent

›Factors commonly used

›Age

›Smoking exposure

›Degree of hematuria on microscopy

›History of gross hematuria

›Stone probability tools

›STONE score for suspected ureteral stone

›Limitations

›Does not exclude alternative dangerous diagnoses

›Performance varies by setting

MRI

›MRI urography indications

›CT contrast contraindication with high suspicion of upper tract pathology

›Pregnancy when ultrasound non diagnostic and benefits outweigh risks local protocol dependent

›MRI limitations

›Longer acquisition time

›Limited availability in ED workflow

›CT for suspected stone

›Noncontrast CT KUB

›High sensitivity for ureteral calculi

›CT urogram for malignancy evaluation

›Gross hematuria evaluation in appropriate risk groups local protocol dependent

›Contrast risks

›Kidney dysfunction

13Special Tests/spec27

Bedside and procedural diagnostics

›Bladder catheter evaluation

›Difficulty voiding with suprapubic fullness supports retention

›Gross blood return suggests lower tract source or severe bleeding

›Continuous bladder irrigation pathway local protocol dependent

›Three way catheter use with urology guidance

›Irrigation endpoint targets

›Light pink urine

›No recurrent clots

Specialty evaluation tests

›Cystoscopy

›Indications

›Gross hematuria without clear benign explanation

›Persistent microscopic hematuria in appropriate risk tier

›Limitations

›Does not fully evaluate upper tract

›Scheduling dependent on resources

›Urine cytology

›Higher utility in high risk urothelial carcinoma suspicion

›Limitations

›Lower sensitivity for low grade tumors

›Not a rule out test

Nephrology directed testing

›Glomerular workup when suspected

›Urine protein to creatinine ratio

›Serologies guided by syndrome

›C3 and C4

›ANA

14ECG/ecg11

Indications in hematuria presentations

›ECG triggers

›Syncope or presyncope

›Chest pain

›Significant anemia concern

›Electrolyte and renal complication triggers

›Hyperkalemia concern

›Severe hypertension with symptoms

High risk findings

›Concerning ECG patterns

›Ischemic ST changes

›Wide complex rhythm

›Bradycardia with hyperkalemia pattern suspicion

15Assessment/ax26

Problem representation

›Hematuria classification

›Gross hematuria

›Microscopic hematuria

›Suspected glomerular

›Suspected nonglomerular

›Severity stratification

›Stable without anemia symptoms

›Symptomatic anemia

›Hemodynamic instability

Working diagnosis candidates

›Likely diagnosis with ICD 10 where applicable

›UTI (N39.0)

›Pyuria on microscopy

›LUTS present

›Nephrolithiasis (N20.0)

›Colicky flank pain

›Hydronephrosis on ultrasound or stone on CT

›Glomerulonephritis (N05.9)

›Proteinuria

›Dysmorphic RBC or casts

Complications to rule out

›Time critical complications

›Clot retention with obstruction

›Obstructed infected system

›Significant anemia

›Alternate dangerous diagnoses

›GU trauma

16Plan/plan41

First 5 minutes and stabilization

›Immediate stabilization

›Continuous monitoring when unstable or significant bleeding concern

›Two large bore IV access if shock physiology

›Type and screen if gross hematuria with symptoms or significant ongoing bleeding

›Resuscitation targets

›Crystalloid bolus for hypotension if not cardiogenic

›Blood products per hemorrhage protocol local protocol dependent

Differential Management

›!Hematuria (gross)→›!Urolithiasis (renal colic)→›Urinary tract infection (uncomplicated)→

Diagnostic sequencing

›Initial diagnostic bundle

›UA with microscopy

›CBC

›Creatinine and electrolytes

›Conditional diagnostics

›If fever or systemic toxicity, urine culture and sepsis labs

›If flank pain colic, CT KUB or ultrasound based pathway local protocol dependent

›If suspected glomerular, urine protein quantification and targeted serologies

Therapeutics

›Analgesia and antiemesis

›Acetaminophen oral 1000 mg

›Ondansetron oral dissolving 4 mg

›Infection treatment pathway

›Antibiotics guided by suspected site and local antibiogram local protocol dependent

›If obstructed infected system suspected, broad spectrum IV antibiotics and urgent decompression

17Disposition/dispo24

ICU and high acuity

›ICU criteria

›Ongoing hemodynamic instability

›Ongoing transfusion requirement

›Sepsis with organ dysfunction

›Stepdown or monitored bed criteria

›Significant anemia symptoms without shock

›Persistent gross hematuria requiring continuous bladder irrigation

Inpatient admission

›Admission indications

›Obstructed infected system

›AKI with complications

›Uncontrolled pain or vomiting

›High risk trauma with renal injury

Observation pathway

›Observation appropriate when

›Pain control requires serial dosing

›Serial hemoglobin monitoring needed without active shock

Discharge criteria and follow up

›Discharge criteria

›Hemodynamically stable

›Able to void without retention

›Pain controlled on oral regimen

›No sepsis physiology

›Follow up timing

›Urology follow up for gross hematuria or persistent microscopic hematuria

›Nephrology follow up for suspected glomerular source

›Primary care follow up for repeat UA timing local protocol dependent

18Discharge Instructions/di24

Copy discharge instructions

›Diagnosis summary

›Blood was seen in your urine today

›Some causes are harmless and some need more testing

›What was checked today

›Urine testing

›Blood testing

›Imaging if performed

›Medications

›Take prescribed antibiotics exactly as directed if given

›Avoid NSAIDs if kidney problems were discussed

›Hydration and activity

›Drink fluids unless you were told to restrict fluids

›Avoid strenuous exercise until symptoms improve

›Follow up

›Follow up with urology if you had visible blood in urine or if urine tests stay abnormal

›Follow up with your family doctor for repeat urine testing as instructed

›Return to ED now for

›Inability to urinate

›Passing large clots

›Fainting or severe weakness

›Chest pain or shortness of breath

›Fever or shaking chills

›Severe flank pain

›Worsening bleeding

19References/r15

Guidelines and key sources

›American Urological Association and Society of Urodynamics Female Pelvic Medicine and Urogenital Reconstruction microhematuria guideline 2020 amended 2025

›Risk stratified evaluation framework for microscopic hematuria

›Imaging and cystoscopy recommendations by risk tier

›European Association of Urology guidelines on urological infections 2024

›Pyelonephritis and urosepsis principles

›Obstructed infection decompression urgency

›European Association of Urology urolithiasis guideline 2024

›Imaging approaches and management pathways for ureteral stones

›Indications for urgent intervention

›American College of Radiology appropriateness criteria hematuria 2023

›Modality selection by clinical scenario

›CT urogram indications and limitations

›Kidney Disease Improving Global Outcomes glomerulonephritis guideline 2021

›Syndrome based evaluation for suspected glomerular hematuria

›Indications for nephrology referral

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

HematuriaAPPROACH

RENAL AND URINARY · 19 SECTIONS

⚲

561 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Oliguria And Anuria Catheter Related Urinary Complaints Dialysis Patient Presentations Flank Pain And Renal Colic Concern Urinary Retention Hematuria Scrotal Pain

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx82

HPI overview

›Hematuria presentation framing

›Gross hematuria

›Microscopic hematuria

›First episode

›Recurrent

›Bleeding pattern

›Initial stream

›Terminal

›Total

›Clots

Onset

›Onset timing

›Sudden

›Gradual

›After trigger

›Temporal context

›After exercise

›After trauma

›After procedure

›During infection symptoms

Provocation/Palliation

›Triggers

›Exertion

›Recent sexual activity

›Recent instrumentation

›Recent anticoagulant change

›Modifiers

02Alarm Features/alarm32

Immediate life threats

›Life threatening hematuria pathways

›Clot retention with obstructive uropathy

›Hemorrhagic shock

›Sepsis from obstructed infected system

›Trauma with renal vascular injury

Vital sign danger thresholds

›Hemodynamic instability thresholds

›SBP under 90 mmHg

›HR over 120

›Shock index over 1

›Sepsis physiology thresholds

›Temperature 38.0 C or higher

›RR 22 or higher

›Altered mental status

High risk historical triggers

›High risk triggers

›Recent urinary tract instrumentation

›Known renal mass

›Known bladder tumor

›Recent major trauma

›High risk populations

›Solitary kidney

›Kidney transplant recipient

›Immunocompromised state

›Pregnancy

High risk exam findings

›High risk findings

03Medications/meds27

Bleeding and renal relevant agents

›Antithrombotics and anticoagulants

›Warfarin

›DOACs

›Heparins

›Antiplatelets

›Nephrotoxic exposures

›NSAIDs

›Aminoglycosides

›IV contrast within prior 72 hours

›Hemorrhagic cystitis associated therapies

›Cyclophosphamide

›Ifosfamide

›Pelvic radiation history

Recent medication changes

›Change timeline

›New start within 30 days

›Dose escalation within 30 days

›Missed doses

›Interactions that increase bleeding

›SSRIs and SNRIs

›Azole antifungals

›Macrolides

Contraindications to likely therapies

›Analgesic considerations

›NSAID avoidance in suspected glomerulonephritis or AKI

›Opioid cautions in older adults and renal impairment

›Contrast considerations

04Diet/diet11

Exposure patterns

›Hydration pattern

›Poor intake

›High fluid intake

›Recent vomiting or diarrhea

›Food and supplement discoloration

›Beets

›Rhubarb

›B vitamins

›Alcohol exposure

›Heavy recent use

›Withdrawal risk context

05Review of Systems/ros28

Gen constitutional

›Constitutional symptoms

›Fever

›Chills

›Night sweats

›Unintentional weight loss

›Urinary symptoms

›Dysuria

›Frequency

›Urgency

›Retention

›Stone symptoms

›Colicky flank pain

›Radiation to groin

Cardiorespiratory

›Anemia and ischemia symptoms

›Chest pain

›Dyspnea

›Palpitations

›Thromboembolic context

›Leg swelling

›Pleuritic pain

Skin and MSK

›Vasculitis and systemic disease clues

›Purpura

›Arthralgias

›Oral ulcers

06Collateral History and Family History/chafh15

Collateral sources

›Source reliability

›Patient report reliability

›Family or caregiver collateral

›EMS documentation

Family history

›Malignancy and inherited renal disease

›Urothelial cancer in first degree relative

›Kidney cancer in first degree relative

›Polycystic kidney disease

›Alport syndrome

›Stone disease

›Recurrent nephrolithiasis in family

›Cystinuria history

Household and exposure context

›Infectious exposures

›Sick contacts

›Recent travel with schistosomiasis exposure risk

07Risk Factors/rf30

Malignancy risk

›Urothelial malignancy risk factors

›Age 35 or older

›Smoking history

›Occupational aromatic amine exposure

›Prior pelvic radiation

›High risk clinical features

›Gross hematuria

›Persistent microscopic hematuria

Stone and obstruction risk

›Nephrolithiasis risks

›Prior stones

›Low fluid intake

›Hyperparathyroidism history

›Obstruction risks

›Benign prostatic hyperplasia

›Neurogenic bladder

Glomerular disease risk

›Immune and inflammatory risks

›Recent streptococcal infection

›SLE

›IgA vasculitis history

›Metabolic risks

›Diabetes mellitus (E11.9)

›Hypertension (I10)

Infection risk

›UTI and pyelonephritis risks

›Prior recurrent UTI

08Differential Diagnosis/ddx51

Life threatening

›Cannot miss diagnoses

›Obstructed infected collecting system

›Fever

›Flank pain

›Hydronephrosis

›Major genitourinary trauma

›Mechanism with deceleration or flank impact

›Gross hematuria

›Flank ecchymosis

›Urothelial malignancy (C67.9)

›Painless gross hematuria

›Smoking history

›Renal cell carcinoma (C64.9)

›Flank mass

›Weight loss

Common

›Common etiologies

›Urinary tract infection (N39.0)

›Dysuria

›Positive nitrites or leukocyte esterase

›Nephrolithiasis (N20.0)

›Colicky flank pain

›Microscopic hematuria

›Benign prostatic hyperplasia (N40.0)

›Weak stream

›Incomplete emptying

›Menstrual contamination

09Past Medical History/pmh21

Prior GU history

›Prior urologic conditions

›Prior hematuria workup results

›Prior cystoscopy results

›Prior CT urogram results

›Stones and infections

›Prior nephrolithiasis episodes

›Prior pyelonephritis

Chronic disease and special populations

›Renal and systemic disease

›Chronic kidney disease (N18.9)

›Polycystic kidney disease (Q61.3)

›Sickle cell disease (D57.1)

›Bleeding risk conditions

›Cirrhosis (K74.60)

›Known thrombocytopenia

Prior procedures and devices

›GU procedures

›TURP history

›Ureteral stent history

›Nephrostomy history

›Devices

›Indwelling urinary catheter

›Recent catheter change

10Physical Exam/exam33

General and vitals

›General appearance and perfusion

›Toxic appearance

›Pallor

›Diaphoresis

›Vital sign patterns

›Tachycardia

›Hypotension

›Fever

Abdomen and flank

›Abdominal exam cluster

›Suprapubic tenderness

›Suprapubic distension

›Peritonitis signs

›Flank exam cluster

›CVA tenderness

›Flank ecchymosis

GU and pelvic

›External GU inspection

›Meatal bleeding

›Scrotal or penile trauma signs

›Pelvic considerations

›Vaginal bleeding source possibility

›Cervical motion tenderness context

Skin and extremities

›Systemic disease clues

›Purpura

›Edema

11Lab Studies/labs28

Urinalysis and microscopy

›UA interpretation framework

›Dipstick heme positive with RBC on microscopy supports hematuria

›Dipstick heme positive with few RBC suggests hemoglobinuria or myoglobinuria

›Microscopy features

›Dysmorphic RBC suggests glomerular source

›RBC casts suggest glomerulonephritis

›Proteinuria degree supports glomerular process

Infection evaluation

›Infectious labs

›Urine culture

›CBC with differential

›Sepsis adjuncts if systemic features

›Serum lactate

›Blood cultures before antibiotics when feasible

Renal function and bleeding

›Renal and electrolyte labs

›Creatinine and eGFR baseline comparison

›Potassium and bicarbonate for AKI complications

›Hemostasis labs

›INR for warfarin exposure

›Platelet count

›Fibrinogen if massive bleeding concern

Rhabdomyolysis and hemolysis

›Pigment workup when heme positive with few RBC

›CK

›Hemolysis labs

›LDH

12Imaging/img35

Scoring Systems

›Risk stratification for microscopic hematuria workup

›Malignancy risk tiering per urology guideline local protocol dependent

›Factors commonly used

›Age

›Smoking exposure

›Degree of hematuria on microscopy

›History of gross hematuria

›Stone probability tools

›STONE score for suspected ureteral stone

›Limitations

›Does not exclude alternative dangerous diagnoses

›Performance varies by setting

MRI

›MRI urography indications

›CT contrast contraindication with high suspicion of upper tract pathology

›Pregnancy when ultrasound non diagnostic and benefits outweigh risks local protocol dependent

›MRI limitations

›Longer acquisition time

›Limited availability in ED workflow

›CT for suspected stone

›Noncontrast CT KUB

›High sensitivity for ureteral calculi

›CT urogram for malignancy evaluation

›Gross hematuria evaluation in appropriate risk groups local protocol dependent

›Contrast risks

›Kidney dysfunction

13Special Tests/spec27

Bedside and procedural diagnostics

›Bladder catheter evaluation

›Difficulty voiding with suprapubic fullness supports retention

›Gross blood return suggests lower tract source or severe bleeding

›Continuous bladder irrigation pathway local protocol dependent

›Three way catheter use with urology guidance

›Irrigation endpoint targets

›Light pink urine

›No recurrent clots

Specialty evaluation tests

›Cystoscopy

›Indications

›Gross hematuria without clear benign explanation

›Persistent microscopic hematuria in appropriate risk tier

›Limitations

›Does not fully evaluate upper tract

›Scheduling dependent on resources

›Urine cytology

›Higher utility in high risk urothelial carcinoma suspicion

›Limitations

›Lower sensitivity for low grade tumors

›Not a rule out test

Nephrology directed testing

›Glomerular workup when suspected

›Urine protein to creatinine ratio

›Serologies guided by syndrome

›C3 and C4

›ANA

14ECG/ecg11

Indications in hematuria presentations

›ECG triggers

›Syncope or presyncope

›Chest pain

›Significant anemia concern

›Electrolyte and renal complication triggers

›Hyperkalemia concern

›Severe hypertension with symptoms

High risk findings

›Concerning ECG patterns

›Ischemic ST changes

›Wide complex rhythm

›Bradycardia with hyperkalemia pattern suspicion

15Assessment/ax26

Problem representation

›Hematuria classification

›Gross hematuria

›Microscopic hematuria

›Suspected glomerular

›Suspected nonglomerular

›Severity stratification

›Stable without anemia symptoms

›Symptomatic anemia

›Hemodynamic instability

Working diagnosis candidates

›Likely diagnosis with ICD 10 where applicable

›UTI (N39.0)

›Pyuria on microscopy

›LUTS present

›Nephrolithiasis (N20.0)

›Colicky flank pain

›Hydronephrosis on ultrasound or stone on CT

›Glomerulonephritis (N05.9)

›Proteinuria

›Dysmorphic RBC or casts

Complications to rule out

›Time critical complications

›Clot retention with obstruction

›Obstructed infected system

›Significant anemia

›Alternate dangerous diagnoses

›GU trauma

16Plan/plan41

First 5 minutes and stabilization

›Immediate stabilization

›Continuous monitoring when unstable or significant bleeding concern

›Two large bore IV access if shock physiology

›Type and screen if gross hematuria with symptoms or significant ongoing bleeding

›Resuscitation targets

›Crystalloid bolus for hypotension if not cardiogenic

›Blood products per hemorrhage protocol local protocol dependent

Differential Management

›!Hematuria (gross)→›!Urolithiasis (renal colic)→›Urinary tract infection (uncomplicated)→

Diagnostic sequencing

›Initial diagnostic bundle

›UA with microscopy

›CBC

›Creatinine and electrolytes

›Conditional diagnostics

›If fever or systemic toxicity, urine culture and sepsis labs

›If flank pain colic, CT KUB or ultrasound based pathway local protocol dependent

›If suspected glomerular, urine protein quantification and targeted serologies

Therapeutics

›Analgesia and antiemesis

›Acetaminophen oral 1000 mg

›Ondansetron oral dissolving 4 mg

›Infection treatment pathway

›Antibiotics guided by suspected site and local antibiogram local protocol dependent

›If obstructed infected system suspected, broad spectrum IV antibiotics and urgent decompression

17Disposition/dispo24

ICU and high acuity

›ICU criteria

›Ongoing hemodynamic instability

›Ongoing transfusion requirement

›Sepsis with organ dysfunction

›Stepdown or monitored bed criteria

›Significant anemia symptoms without shock

›Persistent gross hematuria requiring continuous bladder irrigation

Inpatient admission

›Admission indications

›Obstructed infected system

›AKI with complications

›Uncontrolled pain or vomiting

›High risk trauma with renal injury

Observation pathway

›Observation appropriate when

›Pain control requires serial dosing

›Serial hemoglobin monitoring needed without active shock

Discharge criteria and follow up

›Discharge criteria

›Hemodynamically stable

›Able to void without retention

›Pain controlled on oral regimen

›No sepsis physiology

›Follow up timing

›Urology follow up for gross hematuria or persistent microscopic hematuria

›Nephrology follow up for suspected glomerular source

›Primary care follow up for repeat UA timing local protocol dependent

18Discharge Instructions/di24

Copy discharge instructions

›Diagnosis summary

›Blood was seen in your urine today

›Some causes are harmless and some need more testing

›What was checked today

›Urine testing

›Blood testing

›Imaging if performed

›Medications

›Take prescribed antibiotics exactly as directed if given

›Avoid NSAIDs if kidney problems were discussed

›Hydration and activity

›Drink fluids unless you were told to restrict fluids

›Avoid strenuous exercise until symptoms improve

›Follow up

›Follow up with urology if you had visible blood in urine or if urine tests stay abnormal

›Follow up with your family doctor for repeat urine testing as instructed

›Return to ED now for

›Inability to urinate

›Passing large clots

›Fainting or severe weakness

›Chest pain or shortness of breath

›Fever or shaking chills

›Severe flank pain

›Worsening bleeding

19References/r15

Guidelines and key sources

›American Urological Association and Society of Urodynamics Female Pelvic Medicine and Urogenital Reconstruction microhematuria guideline 2020 amended 2025

›Risk stratified evaluation framework for microscopic hematuria

›Imaging and cystoscopy recommendations by risk tier

›European Association of Urology guidelines on urological infections 2024

›Pyelonephritis and urosepsis principles

›Obstructed infection decompression urgency

›European Association of Urology urolithiasis guideline 2024

›Imaging approaches and management pathways for ureteral stones

›Indications for urgent intervention

›American College of Radiology appropriateness criteria hematuria 2023

›Modality selection by clinical scenario

›CT urogram indications and limitations

›Kidney Disease Improving Global Outcomes glomerulonephritis guideline 2021

›Syndrome based evaluation for suspected glomerular hematuria

›Indications for nephrology referral

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.