Hematuria and Other Abnormal Urinalysis Findings

Microscopic hematuria algorithm, from AUA Guidelines

Assessing hematuria risks


Risk factors

Hematuria workup

Risk Groups

Risk Needs all criteria? Age Smoking
(UA x1)
Urothelial cancer
risk factors*
Prior hematuria Probability malignant cause Recommendations
Low Yes Women < 50
Men < 40
< 10 3-10 None No 0.2-0.5% Repeat UA in 6mo, OR...
Cysto + renal US
Intermediate No Women 50-59
Men 40-59
10-30 11-25 1+ Persistent 3-10 RBC 1.3-1.6% Cysto + renal US
High No 60+ > 30 > 25 - Gross 10.8-11.1% Cysto + CTU

*Risk factors include increased age, male, prior smoking, irritative voiding symptoms, prior pelvic radiation, prior cyclophosphamide, history urothelial cancer or Lynch syndrome, prior occupational exposures, and chronic indwelling foreign body


Workup components


Hematuria grading scale Option #1, from Lee 2013

Hematuria grading scale Option #2, from Stout 2021

Glomerular causes of hematuria, from Campbell's

Hematuria management

Initial Evaluation of Gross Hematuria


Prostate Cancer


Upper tract causes

Random causes of hematuria to rule out

Hemorrhagic Cystitis

Common Causes

Medical Management

Drug Mechanism Dosing Considerations Needs OR/Anesthesia? Contraindications Side effects
Aluminum ammonium sulfate
Aluminum potassium sulfate
Protein precipitation
1% solution (10g/L)
run at 200-300mL/hr
Success: 45-100%
No need for anesthesia
Can give with VUR
No None Aluminum toxicity
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)
Upper tract bleeding (causes glomerular thrombosis)
Risk factors for thrombosis
Rhabdomyolysis (monitor CPK if used for > 24hr)
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

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

Sterile Pyuria

Common Causes


Different causes of urine color, from Campbell's

Proteinuria algorithm, from Campbell's

Other UA findings

Things that look like hematuria but aren't hematuria

Non-hematuria findings