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Immediate stabilization
High risk presentation
Hemodynamic instability
Escalate to resuscitation bay for SBP < 90 mmHg
Escalate to resuscitation bay for altered mental status
Ongoing brisk bleeding
Activate massive transfusion protocol for suspected hemorrhagic shock
Early urology consult for suspected clot retention with obstruction
Urinary obstruction
If inability to void with suprapubic pain, treat as clot retention until proven otherwise
If anuria with flank pain, urgent imaging for obstruction
Initial monitoring
Continuous cardiac monitoring
Telemetry for active bleeding or anemia
Frequent blood pressure checks
Arterial line if rapidly changing hemodynamics
Strict intake and output
Urine output target 0.5 ml/kg/hour
Access and resuscitation
Two large bore IV lines
If difficult access, intraosseous access
Balanced crystalloid only for temporizing hypotension
Transition to blood products for suspected hemorrhagic shock
Transfusion thresholds
If active bleeding, transfuse based on physiology and ongoing loss rather than a single hemoglobin value
If coronary disease or symptoms, consider higher hemoglobin threshold
Time critical causes and triggers
Cannot miss etiologies
Malignancy
Bladder cancer
Upper tract urothelial carcinoma
Renal cell carcinoma
Vascular catastrophe
Abdominal aortic aneurysm with aortoenteric fistula
Renal infarction
Severe infection
Urosepsis with hematuria
Emphysematous cystitis
Obstruction complications
Bilateral obstruction
Solitary kidney obstruction
Escalation triggers
If fever with rigors, early antibiotics after cultures
If hypotension, sepsis bundle
If severe flank pain, urgent CT for stone with obstruction
If infected obstruction, emergent decompression pathway
If painless gross hematuria, malignancy workup pathway
Arrange cystoscopy and upper tract imaging
Key concepts
Framework
Source localization
Glomerular pattern
Non glomerular pattern
Severity assessment
Hemodynamic impact
Clot retention risk
Medication contribution
Anticoagulants
Antiplatelets
Urologic cancer risk
Age and smoking history
Prior pelvic radiation
Occupational exposures
Presenting features
Symptom characterization
Gross hematuria timing
Initial stream
Terminal stream
Total stream
Clots
Clot passage
Urinary retention episodes
Pain pattern
Flank colic pattern
Suprapubic pain pattern
Painless hematuria
Associated urinary symptoms
Dysuria
Frequency
Urgency
Systemic symptoms
Fever
Weight loss
Timing and exposures
Recent trauma
Blunt abdominal trauma
Straddle injury
Recent procedures
Foley catheterization
Cystoscopy
Ureteroscopy
Exercise association
Post exertional hematuria
Persistent hematuria after 72 hours
Risk factors and comorbidities
Malignancy risk
Age over 35 years
Higher malignancy probability with increasing age
Tobacco exposure
Pack year history
Chemical exposures
Aromatic amines
Industrial dyes
Prior pelvic radiation
Radiation cystitis
Bleeding risk
Anticoagulants
Warfarin
DOAC use
Antiplatelets
Aspirin
P2Y12 inhibitors
Liver disease
Coagulopathy history
Known thrombocytopenia
Prior low platelets
Renal disease risk
Glomerulonephritis history
Prior nephritic syndrome
Recent infection
Pharyngitis
Skin infection
Autoimmune disease
SLE
Vasculitis
Infection and stone risk
Recurrent UTI
Multidrug resistant organisms
Nephrolithiasis history
Prior stones
Dehydration
Low fluid intake
General and hemodynamics
Stability assessment
Vital signs
Hypotension
Tachycardia
Perfusion
Delayed capillary refill
Cool extremities
Mental status
Confusion
Syncope
Bleeding burden clues
Pallor
Conjunctival pallor
Volume status
Orthostasis
Visible urine inspection
Red urine
Tea or cola urine
Abdominal and genitourinary exam
Abdominal findings
Costovertebral angle tenderness
Unilateral
Bilateral
Suprapubic tenderness
Distended bladder
Palpable mass
Renal mass concern
External genital exam
Urethral meatus blood
Trauma concern
Testicular pain or swelling
Alternative diagnosis
Pelvic exam when indicated
Vaginal bleeding vs hematuria
Source clarification
Cervical lesions or bleeding
Alternative source
PITFALLS
Common pitfalls
Normal vitals do not exclude significant blood loss
Early compensation in young patients
Anticoagulant associated hematuria still needs malignancy evaluation
Anticoagulants may unmask underlying lesions
Red urine is not always hematuria
Menstrual contamination
Myoglobinuria
Life threatening and high consequence
Immediate threats
Malignancy
Bladder cancer
ICD-10 C67
Renal cell carcinoma
ICD-10 C64
Upper tract urothelial carcinoma
ICD-10 C65 C66
Severe bleeding or obstruction
Clot retention with urinary obstruction
ICD-10 R33
Hemorrhagic shock
ICD-10 R57.1
Infected obstruction
Obstructing stone with sepsis
ICD-10 N20 with A41
Common etiologies by pattern
Painful hematuria
Urolithiasis
ICD-10 N20
Pyelonephritis
ICD-10 N10
Cystitis
ICD-10 N30
Trauma
Renal contusion laceration
Painless hematuria
Bladder tumor
Classic presentation
Benign prostatic hyperplasia bleeding
ICD-10 N40
Renal mass
Renal cell carcinoma
Anticoagulant associated bleeding
Still evaluate for structural lesion
Glomerular pattern
IgA nephropathy
Gross hematuria after URI
Post infectious glomerulonephritis
Nephritic syndrome
ANCA associated vasculitis
Systemic symptoms
Mimics and non hematuria causes
Pseudohematuria
Pigments
Beet ingestion
Rifampin
Myoglobinuria
Rhabdomyolysis
Hemoglobinuria
Hemolysis
Core labs
Initial laboratory panel
Urinalysis with microscopy
RBC count confirmation
RBC morphology
Proteinuria
Casts
Complete blood count for anemia and infection
Hemoglobin trend if ongoing bleeding
Platelet count for bleeding risk
Basic metabolic panel for kidney function
Creatinine baseline for imaging planning
Potassium for obstruction and AKI
Hemostasis and transfusion
Coagulation assessment
INR for warfarin effect
Therapeutic vs supratherapeutic
aPTT if heparin exposure
Excess anticoagulation concern
Fibrinogen if massive bleeding
Low fibrinogen replacement trigger
Type and screen
Active bleeding
Crossmatch for anticipated transfusion
Planned operative intervention
Pre procedure preparation
Infection and systemic workup
Infection evaluation
Urine culture
Complicated UTI suspicion
Blood cultures
If fever or sepsis concern
Lactate in suspected sepsis
Resuscitation endpoint support
Glomerular disease labs when indicated
Urine protein creatinine ratio
Nephritic nephrotic overlap
Complement levels
Low complement patterns
ANCA and anti GBM testing
Rapidly progressive glomerulonephritis concern
PITFALLS
Limitations
Urinalysis dipstick heme without RBC
Myoglobinuria
Hemoglobinuria
Contamination
Menstrual blood
Poor collection technique
Scoring Systems
Hematuria risk stratification
AUA risk concepts
Gross hematuria as high risk for malignancy
Older age and smoking as higher risk features
Glomerular vs non glomerular pattern
Proteinuria and casts supporting glomerular source
Clots supporting lower tract source
MRI
MRI urography
Indications
Iodinated contrast allergy with need for upper tract imaging
Pregnancy selected cases after risk benefit discussion
Limitations
Lower sensitivity for small urothelial lesions vs CT urography
Limited acute ED availability
CT
CT selection by syndrome
CT urogram multiphase
High risk hematuria evaluation
Upper tract urothelial assessment
CT KUB non contrast
Suspected stone disease
Flank pain with hematuria
CT abdomen pelvis with IV contrast
Suspected renal mass
Trauma evaluation per protocol
Contrast safety
Baseline creatinine
Weigh risk benefit in severe AKI
Hydration strategy
Use isotonic fluids when clinically appropriate
Ultrasound
Point of care ultrasound
Bladder volume assessment
Retention with clot suspicion
Catheter position confirmation
Hydronephrosis assessment
Obstruction screening
Bilateral hydronephrosis concern
Formal ultrasound
Renal bladder ultrasound
Pregnancy preferred initial imaging for stones
Children preferred initial imaging for stones
Limitations
Poor sensitivity for small stones
Limited detection of urothelial malignancy
Admission and level of care
Admission criteria
Hemodynamic instability or syncope
ICU or stepdown depending on support needs
Ongoing transfusion requirement
Monitored bed
Clot retention
Urology admission or observation with irrigation plan
Infected obstruction
Emergent urology intervention pathway
Transfer criteria
No urology coverage with clot retention
Transfer after stabilization and catheter placement
Suspected malignancy with severe bleeding needing intervention
Transfer to center with endoscopic capabilities
Discharge criteria and follow up
Discharge suitability
Hemodynamically stable
No orthostasis
No clot retention
Adequate spontaneous voiding
Hemoglobin stable on repeat testing when clinically indicated
No concerning downtrend
Pain controlled with oral regimen
Tolerating oral intake
Follow up plan
Gross hematuria
Urology referral for cystoscopy and upper tract imaging
Suspected glomerular disease
Nephrology referral
UTI treated
Culture review and antibiotic adjustment pathway
Immediate urinary tract management
Clot retention pathway
Three way catheter placement
Large bore catheter
22 to 24 Fr preferred for clot evacuation
If urethral trauma concern, urology before catheterization
Retrograde urethrogram pathway
Manual irrigation
Sterile saline irrigation until return clears of clots
If inability to clear, urgent urology for cystoscopic evacuation
Continuous bladder irrigation
Initiate CBI after large clots cleared
Titrate irrigation rate to light pink effluent
Hemorrhage and anemia
Transfusion
Packed RBC transfusion
If symptomatic anemia
Chest pain
Dyspnea
Syncope
If ongoing brisk bleeding with instability
Transfuse without waiting for labs
Platelets
If severe thrombocytopenia with active bleeding
If platelet dysfunction with life threatening bleeding
Hemostatic adjuncts
Intravesical agents
Alum irrigation
Urology guided use for refractory bladder bleeding
Intravesical aminocaproic acid
Urology guided use for refractory bleeding
Systemic antifibrinolytics
Tranexamic acid IV
Consider only with specialist input for severe refractory hematuria
Avoid if active upper tract bleeding with obstruction risk concern
Infection treatment
Suspected cystitis
Antibiotics per local resistance patterns
Tailor to culture results
Symptom control
Phenazopyridine short course if appropriate renal function
Suspected pyelonephritis or urosepsis
Broad spectrum IV antibiotics
Cover gram negatives
Add enterococcus coverage when risk factors present
Source control
If obstructed infected system, emergent decompression
Anticoagulant and antiplatelet related bleeding
Warfarin associated major bleeding
Vitamin K IV
10 mg IV for life threatening bleeding
Four factor PCC
Weight based dosing per INR category
Repeat INR after reversal
Dabigatran associated major bleeding
Idarucizumab
5 g IV total dose
Factor Xa inhibitor associated major bleeding
Four factor PCC
50 units/kg IV when life threatening bleeding and andexanet unavailable or not used
Andexanet alfa
Use per institutional protocol and indication
Antiplatelet associated major bleeding
Platelet transfusion
Consider for life threatening bleeding with recent antiplatelet ingestion
Desmopressin
0.3 mcg/kg IV for platelet dysfunction support in selected cases
Pain and spasm control
Renal colic pattern
NSAID therapy
Ketorolac IV
15 mg IV
Avoid in severe AKI
Opioid rescue
If NSAID contraindicated or inadequate
Bladder spasm with catheter
Anticholinergic therapy
Oxybutynin PO
5 mg PO
Caution in older adults delirium risk
Pregnancy
Pregnancy considerations
Source clarification
Vaginal bleeding vs hematuria
Placental causes outside urinary tract
Imaging strategy
Renal bladder ultrasound first line for stones
MRI urography as second line when needed
Medication safety
Avoid NSAIDs in later pregnancy
Antibiotic selection pregnancy safe options
Geriatric
Older adult considerations
High malignancy pretest probability
Expedite urology follow up for cystoscopy
Medication risks
Anticholinergic delirium risk
NSAID renal and GI risk
Anticoagulant use prevalence
Lower threshold for coagulation testing and reversal discussion
Pediatrics
Pediatric considerations
Common etiologies
Post infectious glomerulonephritis
Hypercalciuria
Trauma
Imaging strategy
Ultrasound first line for stones
CT reserved for selected cases due to radiation
Weight based dosing
Analgesics weight based protocols
Antibiotics weight based protocols
Epidemiology
Frequency and significance
Gross hematuria as high risk symptom
Increased probability of urologic malignancy vs microscopic hematuria
Age distribution
Malignancy risk increases with age
Smoking association
Strong risk factor for urothelial carcinoma
Pathophysiology
Source categories
Glomerular bleeding
Dysmorphic RBC and casts
Proteinuria common
Nonglomerular renal bleeding
Stones
Tumor
Infection
Lower tract bleeding
Bladder tumor
Prostate bleeding
Cystitis
Clot formation mechanisms
Lower tract bleeding more likely to clot
Clots suggest bladder or prostate source
Obstruction pathway
Clot ball valve effect
Retention and hydronephrosis risk
Therapeutic Considerations
Treatment priorities
Stabilize hemodynamics before definitive diagnostics in unstable patient
Blood products when indicated
Relieve obstruction
Catheterization and irrigation
Identify serious causes
Malignancy evaluation even when anticoagulant related
Evidence and guideline notes
Gross hematuria evaluation generally includes cystoscopy and upper tract imaging
Align with urology society guidance and cancer risk stratification
Antibiotics for infection should be culture directed when possible
Avoid unnecessary antibiotics in asymptomatic bacteriuria
copy discharge instructions
Discharge instructions
Diagnosis
Blood in urine
Home care
Hydration
Avoid strenuous exercise for 48 hours if exercise related
Medication review with prescriber for blood thinners
Follow up
Urology appointment for cystoscopy and imaging
Primary care visit for lab review if kidney function abnormal
Return to ED now
Inability to urinate
Large clots
Worsening bleeding
Dizziness or fainting
Chest pain
Fever
Severe flank pain
Coding references
ICD-10 R31.0 gross hematuria
SNOMED CT gross hematuria concept
Guidelines and key sources
Evidence sources
American Urological Association hematuria guidance
Gross hematuria generally warrants cystoscopy and upper tract imaging
ACEP clinical policy concepts for urinary tract emergencies
Hemodynamic instability triggers resuscitation and transfusion pathways
Coding systems
ICD-10 R31.0 gross hematuria
ICD-10 R31.9 hematuria unspecified
SNOMED CT hematuria and gross hematuria concepts
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.