Management Of Haematuria In Emergency Department.

By Hassan Zahoor.

Areas To Cover

❖ What are the main causes of haematuria ?

❖ What investigations you will do in emergency department ?

❖ How will You manage macroscopic haematuria in ED ?

❖ What is the disposition and follow up?

Causes Of Haematuria

Table 1. Common causes of haematuria2,7,8Category

Benign• Renal masses (eg. angiomyolipoma, oncocytoma)• Benign prostatic hypertrophy• Strictures

Stones• Staghorn calculi• Calcium stones• Uric acid stones

Infective• Pyelonephritis• Cystitis• Urethritis

Trauma• Pelvic trauma• Renal injuries• Foreign bodies

Renal• IgA nephropathy• Thin basement membrane diseases• Hereditary nephritis• Medullary sponge kidney

Iatrogenic• Recent endoscopic procedure (eg. transurethral resection of prostate [TURP])• Transrectal ultrasound (TRUS) guided prostate biopsy• Traumatic catheterisation• Radiation• Indwelling ureteric stents• Renal biopsies• Extracorporeal shockwave lithotripsy

Malignant• Renal cell carcinoma• Transitional cell carcinoma• Squamous cell carcinoma• Urothelial cell carcinoma• Prostate acinar adenocarcimona

Investigations In Emergency Department

❖ Blood : FBC, UE, Coagulation profile, VBG , GH and Cross match if indicated, b HCG

❖ Urine; dipstick, Urine MCS

❖ Imaging : USG renal Tract, CT KUB, Xray KUB,

Management in ED

❖ Goals Of treatment:

❖ R- Resuscitation

❖ E- Ensure free urine drainage

❖ S- Safe discharge from ED as appropriate

❖ P- Prompt follow up and further investigations

Resuscitation

❖ Resuscitation should be appropriate depending upon haemodynamic instability.

❖ Blood products should be given ASAP .

❖ Coagulation should be corrected if deranged/ on anticoagulation.

❖ Urology team should be involved soon to consider early intervention to stop bleeding.

Ensure Free Drainage

❖ Free drainage of urine is important to prevent urinary retention and ultimately obstructive uropathy.

❖ Al patients with macroscopic haematuria should be examined carefully to look for retention sec to clots and should have bladder scans.

❖ If they are able to pass urine , must be asked about passing any clots, size of clots and difficulty passing urine.

❖ If clot retention is present then treatment of choice is insertion of 3 way foleys catheter, followed by bladder wash out and irrigation.

Bladder Washout

▪ Use a larger catheter (18-20G) to increase the likelihood of successful passage and to minimise pressure/area and hence possible trauma (normal urethra should be able to distend to ~1cm without problem – caution if known stricture)

▪ All patients with macroscopic haematuria should have a MANUAL BLADDER WAHOUT performed to remove as much clot as possible to assist in

the resolution of bleeding and to identify those that require urgent cystoscopy prior to going to the ward.▪ use a 60ml syringe▪ fill this with water or saline for irrigation▪ irrigate the bladder via the main drainage port (spigot the irrigation port if using a 3-way IDC) and then aspirate the fluid introduced▪ the goal is to break up the clot within the bladder so it is aspirated into the syringe and then discarded▪ when there is sufficient clot within the syringe, then discard this fluid and use fresh fluid▪ Stuart advises doing at least 10 irrigation/aspirations in 3 separate areas of the bladder (performed by positioning the IDC at 3 different depths) to ensure▪ if after 10-15mins there is still significant ongoing bleeding and clots – consult urology ?need for urgent cystoscopy further manual washout▪ medical students appear to be particularly good at this procedure, and is a resource worth considering!

▪ Once nil significant clots evident on MANUAL BLADDER WASHOUT then proceed to CONTINUOUS BLADDER IRRIGATION via 3-way IDC

with normal saline for irrigation (bags positioned ~1m above patients bladder) and patient may be transferred to the ward

Free Discharge from ED ( Disposition)

❖ Indications For Admission:

❖ Cardiovascular Instability

❖ Clot retention

❖ Uncontrolled pain

❖ Sepsis

❖ Acute renal failure

❖ Coagulopathy

❖ Severe comorbidity

❖ Heavy Haematuria

❖ Social restriction

Safe Discharge Home

❖ If the patient does not have above features can be discharged home BUT will need education to manage haematuria at home and seek medical attention when indicated. Indications for seeking further medical attention would be:

❖ Darkening of haematuria that does not change after few voidings and despite adequate fluid intake.

❖ Increasing clot formation that does not clear easily on voiding and development of urine retention

❖ Worsening pain or fever despite analgesia or antibiotics.

Prompt Follow Up

❖ Preferably discussion with urology reg and follow up within 2 weeks.

❖ Any out patient investigation if indicated.

❖ If patient goes home with catheter follow up with continence clinic for further assessment.

Special Circumstances

❖ Ureteric stones: Often associated, require sufficient analgesia, appropriate investigations, and management depending upon size and site. Infected stones are an emergency.

❖ Solitary Kindney: Low threshold for inpatient investigation nd management

❖ UTI: Should be treated with AB ( oral /Iv) appropriately.

Special Circumstances

❖ Haematuria after trauma:

❖ A) Penetrating injuries should be consulted with urology urgently and investigated as appropriate.

❖ B) Blunt injury to upper tract should have catheter inserted and investigated and admitted.

❖ C) Presence of blood at meatus, perineal bruising, (urethral Injury), bladder injury or penile fracture , urethrogram should be done before attempting cathetrization.

Case 1.

❖ A 60 years old male , presents to Emergency department with complaint of passing blood in urine for last 4 hours. Going to toilet to pass urine every 30 min. Last one hour its becoming more and more painful to pass urine and having suprapubic discomfort. He is a chronic smoker, nil other significant history, not on any regular medications. He did not have similar episode before. Haemodynamically stable. His bladder scan shows 750 ml. Hb on VBG is 110, and you just witnessed frank haematuria on his UA specimen. What are next steps in management??

Case 2.

❖ 55 years old male, BIBA , having frank haematuria for last 6 hours. Had TURP 2 weeks ago, is on warfarin for atrial fibrillation which has been restarted about week ago. was due for INR check by Gp tomorrow. OE HR 115, BP 90/60, HB 82. INR 3.5 . What are next imp steps in management??

Case 3

❖ 65 years old male, from home , presented to ED with complaint of passing blood in urine since morning. Initially dark colour but now light red in colour. Did notice small clots in urine as well, was worried as it is on going. Nil previous episodes. OE HR 85, BP 126/70, HB 126, UA pink coloured urine. Next steps in management??