Gross Hematuria: Just a bit of Kool-Aid

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.

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