Gross hematuria, hemorrhagic syndrome, and clot retention

Definition and clinical significance

Gross hematuria is visible blood in the urine. In an emergency, assess the following in parallel:

• the severity of blood loss;
• whether bleeding is ongoing;
• whether urinary drainage is maintained.

The most dangerous complication is clot formation causing bladder clot retention and acute urinary retention.

Initial assessment

• Hemodynamics, hemoglobin, urine output.
• Clots, pain, and ability to void.
• History: trauma, recent surgery, endoscopic procedures, malignancy, anticoagulants/antiplatelet agents.

In an unstable patient, management of blood loss takes priority over completing the diagnostic workup.

Clot retention

• Urinary drainage must be restored.
• Use a large-bore three-way catheter if insertion is safe.
• Evacuate clots by gentle irrigation with sterile solution.
• Use continuous irrigation if bleeding persists.
• If unsuccessful, perform cystoscopy with clot evacuation and hemostasis.

Anticoagulants

• Establish the drug, indication, time of the last dose, kidney function, and bleeding severity.
• Withhold or reverse anticoagulation as clinically indicated, in consultation with the relevant specialist.
• Local measures alone are insufficient for life-threatening bleeding.

Identifying the cause

After stabilization, identify the source of bleeding:

• Ultrasonography, CT/CT urography, cystoscopy.
• Gross hematuria without an obvious benign cause requires a complete urological evaluation.

Algorithm

Cross-references: Chapters 6, 9–10, 21, and 60–61.