Patients presenting with hematuria can be quite challenging. Like all chief complaints we’ll start by building the differential diagnosis. Think about the anatomy to build the differential for this chief complaint.
Differential Diagnosis
Kidneys:
Nephritic Syndrome
Malignancy
Trauma
Ureters
Kidney stones
Bladder
UTI
Mass
Trauma
Prostate
Prostatic vessels
Urethra
Trauma
History
When obtaining your history ask the patient if there is blood at the beginning, end, or throughout the stream as this may give a clue where the bleeding is coming from.
Beginning: Disease at urethra
End: Disease at bladder neck or prostatic urethral lesion
Throughout: Disease of kidney, ureter, or bladder.
Physical
Check to see if there is blood at the meatus or an external lesion that is causing the bleeding.
Work-Up
Now that we have our differential we can begin to work up our patient. When working up the patient it is important to consider the disposition of the patient and order labs that would effect your disposition. Think about your wild cards (refer to wildcard lecture for more information at https://www.blog.numose.com/emed-basics/wild). Is your patient super old? Are they anticoagulated? Do they have abnormal vital signs? If they meet any of these criteria the patient will have a higher chance of having a significant bleed and will most likely need to be admitted.
So we recommend ordering the following labs for these patients
CBC: See if your patient is anemic or thrombocytopenic
BMP: See if your patient has uremia that could impair platelet aggregation. Also check to see if there is an AKI.
PT/INR/PTT: See if your patient is anticoagulated. Maybe your patient has liver failure and has an elevated inr.
Type and Screen/Cross: Depends on how severe the bleeding is by history and at the time of presentation
Urine Analysis: See if there is an infection
Management Approach
Question 1: Can the patient sufficiently empty bladder. Measure a PVR.
If the patient is retaining place a foley
If the patient is not retaining and does not meet any of the admission criteria below, D/C home
Question 2: Now that the foley is placed can I make the urine clear by irrigated the bladder with 1-2 liters?
If the answer is yes and after an observation period the urine is still clear and the patient does not meet an admission criteria seen below, D/C home
If the answer is no, try 1 more liter.
If you still can’t get the bladder clear, then call urology and admit the patient for continuous bladder irrigation
Remember Kool-Aid color urine is not clear. The reason why you want the urine clear is if you send them home with blood tinged urine they will probably obstruct the foley and bounce back to the ER.
Admission Criteria
If the patient meets any of the following admission should be highly considered.
Hypotensive
Tachycardic
Anemic
Taking Anticoagulants
Thrombocytopenic
Very old
Can’t irrigate to clear
Documentation Pearl
When documenting always be sure to mention that you cannot rule out malignancy. Also be sure to set up urology or a cystoscopy as an outpatient if the patient is going to be d/ced.
ddxof.com Algorithm of Marcroscopic Hematuria
Full ddxof.com article for Macroscopic Hematuria can be found at https://ddxof.com/macroscopic-hematuria/
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