Makindo Medical Notes

Related Subjects: Acute Kidney Injury

🚑 Initial Emergency Management of Severe Haematuria

🚨 The key concern in haematuria is clot retention with urinary tract obstruction. Patients with significant bleeding may need a three-way catheter and continuous bladder irrigation. All patients should undergo renal tract imaging and cystoscopy to exclude malignancy or other serious causes. Avoid TXA as it can cause clot retention

📌 About

• Macroscopic haematuria: red urine visible to the naked eye. May be mimicked by haemoglobinuria, myoglobinuria, porphyrins, or bile pigments → confirm with microscopy.
• Microscopic haematuria: >3–5 RBCs per high-power field on urine microscopy.
• Heavy bleeding with clots can cause anaemia, hypotension, and bladder outlet obstruction.
• In patients >60 years, haematuria is a red flag for urinary tract cancer.
• Urology referral is mandatory in macroscopic haematuria and strongly advised in older patients with microscopic haematuria.

💡 Top Tips

• In a solitary kidney, adopt a lower threshold for inpatient investigation and urgent urology referral.
• Macroscopic haematuria with clots may mimic renal colic → take care not to miss obstruction.
• After pelvic trauma, blood at the meatus or perineal bruising suggests urethral injury. ➡️ Perform a retrograde urethrogram before attempting catheterisation. Early urology input essential.

🔎 Causes

• Malignancy: renal cell carcinoma, urothelial carcinoma (renal pelvis, ureter, bladder), prostate, urethra.
• Stones: renal or ureteric calculi.
• Infection: UTI, schistosomiasis.
• Trauma: blunt or penetrating.
• Benign prostatic hyperplasia (BPH).
• Exercise-induced haematuria (classically post-marathon; can be linked to IgA nephropathy).
• Haemorrhagic cystitis (e.g. cyclophosphamide), Endometriosis.
• Glomerular disease: IgA nephropathy, post-streptococcal GN, vasculitis.
• Post-urological procedures (e.g. TURP).
• Coagulopathy or over-anticoagulation.
• Vascular lesions (AV malformation, angiomyolipoma).

🎨 Other Causes of Red/Discoloured Urine

• Menstruation, Jaundice.
• Foods: beetroot, red cabbage.
• Dyes: paprika, artificial colourings.
• Drugs: rifampicin, metronidazole, nitrofurantoin, warfarin, phenytoin.
• Infections with indigo-positive bacteria (e.g. indoxyl sulphatase activity).
• Rhabdomyolysis (myoglobinuria).
• Metabolic: porphyria, alkaptonuria.

🧑‍⚕️ Clinical Assessment

• Ask: passage of clots, dysuria, frequency, urgency, incontinence.
• Systemic symptoms: fever (UTI), weight loss (malignancy), flank pain (stones).
• Occupational exposure (chemicals, dyes) & smoking history → ↑ risk of bladder TCC.
• Past medical history: bleeding disorders, anticoagulant use.
• Trauma history → avoid catheterisation until urethral injury excluded.
• Recent sore throat/URTI in young patients → think IgA nephropathy.
• Travel history → schistosomiasis → SCC bladder risk.
• Examination: palpable bladder (retention), abdominal mass, DRE, vaginal exam to localise bleeding.
• Note urine colour (rose, claret, “smoky” brown) and presence of clots → helps localisation (glomerular vs post-glomerular).

🧪 Investigations

• Bloods: FBC, U&E + eGFR, clotting screen, PSA (men), β-hCG (fertile females). Group & save if bleeding heavy.
• Urine: Dipstick, microscopy, MSSU.
• Imaging: – Ultrasound ± CT-KUB (stones, tumours). – Plain KUB X-ray (radio-opaque stones). – IVU now rarely used (contrast risk).
• Cystoscopy: gold standard for macroscopic haematuria.

📩 Nephrology Referral

• Proteinuria >2+ on dipstick.
• eGFR <60 mL/min/1.73m².
• Abnormal imaging consistent with intrinsic renal disease.
• Suspected primary renal pathology: IgA nephropathy, Alport’s, thin membrane disease, GN, ADPKD, vasculitis.

🩺 Three-Way Catheter

• Large bore (22–24 Fr) Foley.
• Ports: balloon inflation (20–30 ml water), urine drainage, irrigation fluid entry.
• Manual irrigation with 50 ml sterile water aliquots until clear, then set up continuous bladder irrigation.

⚡ Management

• Admit if: clot retention, haemodynamic instability, uncontrolled pain, sepsis, AKI, coagulopathy, heavy bleeding, severe comorbidity, or poor social support. Encourage high oral fluid intake if safe, to reduce clot formation. Avoid Tranexamic acid.
• Clot retention: insert 3-way catheter + continuous irrigation. If unavailable → large 2-way catheter (≥16 Ch) + manual irrigation, but definitive upgrade needed.
• Suprapubic catheter (SPC): irrigation possible if SPC already in place; avoid fresh insertion if bladder tumour suspected (risk of tumour seeding).
• Coagulopathy: correct anticoagulation as appropriate.
• If bleeding persists: urgent urology review ± surgical/endoscopic haemostasis.
• Blood transfusion if symptomatic anaemia.
• ⚠️ Avoid tranexamic acid → may worsen clot retention.

📚 References

• Management of macroscopic haematuria in the ED
• Oxford Haematuria Guidelines

📌 Revisions

• Streamlined with emphasis on red flags, three-way catheter technique, and referral thresholds.