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Hematuria management

Initial Evaluation of Gross Hematuria

• Safe to discharge: able to empty bladder (check bladder scan), no blood clots (check urine appearance), not actively bleeding (stable Hgb, non-hypotensive)
• Retention with mild bleeding: likely prostatic origin, attempt regular catheter placement (often results in clear yellow urine, catheter bypasses prostatic bleeding)
• Retention likely secondary to clot burden: likely prior XRT or surgery, place large 3-way Rusch catheter, manually irrigate, start continuous bladder irrigation (CBI)
• Persistent bleeding despite CBI: consider traction, OR clot evacuation, other cause-specific treatments

BPH

• Cause: increased vascularity in hyperplastic tissue secondary to VEGF
• Finasteride: inhibits androgen-stimulated angiogenesis and decreases VEGF expression, 90% symptom improvement, decreased need for surgical intervention, can take 2 weeks to 9 months to take effect
• Refractory hematuria: best managed with surgical outlet procedures

Prostate Cancer

• Usually caused by locally advanced cancer with bladder invasion
• Management: consider ADT, palliative XRT, channel TURP, cystoprostatectomy w/ diversion

Urethrorrhagia

• Trauma: most common non-gender specific cause, maintain catheter for 3-7 days
• Urethritis can be infectious or chemical induced
• Urethral tumors: consider if history urothelial cancer

Upper tract causes

• Presentation: clot colic, anemia, and wormlike clots in urine
• Nephropathies: look for dysmorphic RBCs and casts on UA, systemic symptoms
• Papillary necrosis: sickle cell, NSAID use
• Localized management: may require embolization or partial/total nephrectomy

Random causes of hematuria to rule out

• TB/Schistosomiasis: travel to endemic areas
• ADPKD: family history
• Endometriosis or uterouro fistula: cyclical hematuria during menstrual cycle
• Ureteroiliac fistula: hx vascular surgery, chronic ureteral stents, pelvic XRT
• Arteriovenous malformation: may occur if recent renal procedure, treat w/ embolization
• Nutcracker syndrome: compression of renal vein between aorta and SMA

Hemorrhagic Cystitis

Common Causes

• XRT: seen in up to 5% after pelvic XRT
• Chemotherapy: seen in 2-40% after cyclophosphamide, ifosfamide, resolves in 60-90% with mesna
• Viral (BK polyoma): more common in children or immunocompromised

Medical Management

Drug	Mechanism	Dosing	Considerations	Needs OR/Anesthesia?	Contraindications	Side effects
Alum Aluminum ammonium sulfate Aluminum potassium sulfate	Protein precipitation Vasoconstriction	1% solution (10g/L) run at 200-300mL/hr	Success: 45-100% No need for anesthesia Can give with VUR	No	None	Aluminum toxicity
Amicar Aminocaproic acid	Inhibits fibrinolysis	1g/L intravesical 5g PO loading dose + 1g/hr Give for 24hr after hematuria resolves	Success: up to 92%		Bladder clots present (causes them to harden) DIC Upper tract bleeding (causes glomerular thrombosis) Risk factors for thrombosis	Rhabdomyolysis (monitor CPK if used for > 24hr) Hypotension GI effects
Silver Nitrate	Chemical coagulation	0.5-1% instilled for 10-20 minutes Rinse out with saline	Mix with water (will precipitate in saline)	Sometimes (if high concentrations)	Extravasation VUR (need to occlude ureters) Inability to tolerate general/spinal anesthesia	Bladder scarring Ureteral strictures if VUR
Formalin	Cellular protein precipitation	1-4% solution 300mL or up to bladder capacity hold for 10-15 minutes Irrigate bladder with 1L water/saline	Success: 80-90%	Yes

Hyperbaric oxygen

• Technique: 100% O₂ at 2-3 atm, 90 minutes, 30-40 sessions
• Benefits: enhances angiogenesis, vasoconstriction, antibiotic efficacy, neutrophil function
• Absolute contraindications: cisplatin/doxorubicin treatment, untreated pneumothorax, active viral infections
• Relative contraindications: seizure risk, poorly controlled DM, emphysema, optic neuritis, glaucoma, current pregnancy, fever, active malignancy, hx sinus/ear surgery, hx spontaneous pneumothorax, spherocytosis, claustrophobia
• Success for XRT cystitis: 80-90% response rate, but 5yr success only 27%
• Side effects: claustrophobia (20%), otalgia (17%), seizures (rare)

Surgical/procedural interventions

Treatment	Tips
Nephrostomy tubes	Avoids bladder exposure to urokinase, allowing clots to form Can be performed with ureteral coiling
Internal iliac artery embolization	Can be performed unilaterally/bilaterally Posterior occlusion results in significant gluteal pain Success: up to 90%
Cystectomy + Urinary Diversion	Complications in up to 80% if bladder not removed High risk of complications