Haematuria is a common urological presentation with many possible causes. This article provides a systematic approach to managing visible haematuria in urology.
Contents
You’re bleeped: A patient with haematuria
- Definition: Blood in urine. Either visible (macroscopic) or non-visible haematuria (microscopic).
- Why it matters: risk of haemorrhage, clot retention and red-flag for malignancy. [1]
Visible (macroscopic) haematuria. Image from google.
Non-visible (microscopic) haematuria. Image from https://www.sciencephoto.com/media/298949/view/testing-for-blood-in-a-urine-sample
First things first – Assess severity!
- Haematuria severity scale (Look at the tube not the bag!).
- Generally described as, clear, rose, red +/- clots. Presence of clots indicates more severe.
- Assess for haemodynamic stability, Hb.
- If shocked/bleeding → escalate urgently.
- Note: Even 1ml of blood in 1L urine will discolour it. [2]
Degrees of haemturia. Image from https://auanews.net/issues/articles/2023/march-2023/do-we-agree-on-hematuria-evaluating-the-drinks-rating-system
Degrees of haemturia in a catheter tube. Image from https://www.sciencedirect.com/science/article/pii/S0090429520314308
Stop the bleeding
- Insert 3-way catheter (same as a 2 way but just has an extra port for irrigation).
- Manual gentle bladder washouts if clot retention (Click here for video).
- Start irrigation to control ongoing bleeding.
- Monitor resolution by improvement in urine colour.
- If failing: rigid cystoscopy + clot evacuation + haemostasis.
Prevent retention
- Continuous bladder irrigation.
- Do not irrigate if there is no outflow as risk of over inflating/perforating bladder.
- Monitoring output and titrating rate based on urine colour.
- As urine become more clear slows irrigation.
- Stop and consider TWOC when urine is clear again. [3]
Investigate the cause
- Visible haematuria = think cancer.
- Decide if patient can be managed inpatient or outpatient.
- Likely to require a flexible cystoscopy and a CT urogram.
- Visible haematuria always think possibility of cancer.
- USC guidelines (NICE 2ww referrals): age 45 with visible haematuria; age 60 with non-visible haematuria plus dysuria or raised WCC.
- Outpatient workup: USC flexible cystoscopy ± CT urogram.
- Inpatient if unstable, recurrent clot retention, or ongoing transfusion requirement, likely to require inpatient flexible cystoscopy or rigid cystoscopy ± clot evacuation ± haemostasis.[1,4]
Summary
- Haematuria always warrants investigation.
- Initial management priorities:
- Assess severity
- Stop bleeding
- Prevent retention
- Investigate cause
References
[1] Reynard, J., Brewster, S. and Biers, S. (2016a) Oxford Handbook of Urology. Oxford: Oxford University Press. [2] Haematuria – differential diagnosis – investigations (2022) TeachMeSurgery. Available at: https://teachmesurgery.com/urology/presentations/haematuria/ (Accessed: 10 October 2025). [3] Haematuria – differential diagnosis – investigations (2022a) TeachMeSurgery. Available at: https://teachmesurgery.com/urology/presentations/haematuria/#:~:text=the%20renal%20tract-,Management,irrigation%20+/%2D%20evacuation%20of%20clots. (Accessed: 10 October 2025). [4] NICE CKS: Referral for suspected urological cancer (no date) NICE website: The National Institute for Health and Care Excellence. Available at: https://cks.nice.org.uk/topics/urological-cancers-recognition-referral/management/referral-for-suspected-urological-cancer/ (Accessed: 10 October 2025).Written by Kiri Armstrong (FY3)
Edited by Joseph Latham (CT3)
