• On the wards, it is best to think about whether the problem needs to be fixed immediately
• Questions to ask yourself include:
  • Is the patient in urinary retention and do they need a catheter?
  • Does the patient have a urinary tract infection (UTI) and is this causing the haematuria?
  • Does the patient have a urethral injury from a recent catherisation?
  • Is the patient in clot retention?
  • Does the patient have another pathology that needs investigating in hospital or out of hospital?
• Consider common and uncommon causes, and how likely you think any of them might be present:
  • E. Coli UTI is a cause of about 13% of haematuria episodes
  • Less common causes – bladder cancer, kidney cancer, kidney disease, stone disease, prostate cancer, upper tract cancer, radiation cystitis

• It is common for junior doctors to find that once they have inserted a catheter in an elderly patient with urinary retention that there is bright red bleeding from the urethra
  • Sometimes this means there has been a minor urethral injury with the insertion of the catheter
  • Sometimes it can be the catheter passing by the prostate in an elderly gentleman with fragile blood vessels growing over the surface of the prostate (which is quite common)

• Patients with chronic retention can develop decompression haematuria
• There are some theories about the fragility of the blood vessels and that a static pressure from expansion of the bladder with chronic retention can help stop bleeding – usually self-limited. Occasionally it requires active management with washouts and bladder irrigation

• Patients may have a urinary catheter inserted during a cardiac event or vascular event requiring anticoagulation – the trauma of the IDC insertion can be enough to cause haematuria
• BUT, in many patients there may be an underlying bladder or kidney lesion and the herald bleed can be with the commencement of anticoagulation
  • It is common to see a patient on the cardiac ward (e.g. 65 year old smoker with a recent heart attack, started on dual anti-platelets now with a significant haematuria episode), that has a Computed Tomography Intravenous Pyelogram (CT IVP) done and you will see a bladder lesion
  • To avoid missing a bladder lesion, all patients with macroscopic haematuria need a full urological work up

As a minimum:

• Urine cytology x 3
  • Best to collect this as the second void of the day – due to urothelial cells shed in the urine during the first void (cells have been sitting in the urine overnight); these cells can be more degenerated and therefore you can get a higher rate of atypical reporting
• Cystoscopic examination
• CT IVP
  • If the patient is very young and you are worried about radiation exposure, do an ultrasound instead of a CT IVP – note this is less sensitive at detecting cancer (so do this in consultation with the Urologist)

You are a junior doctor on the wards and you arrive to review a patient that has haematuria with clots in the bag. What do you do?

• In patients appearing to have suspected clot retention, give a stat dose of antibiotics – this is because patients can get a septic shower with any blockage of the bladder
  • High risk for infection – IV gentamicin and ampicillin
  • Low risk for infection – IV cephazolin or oral Keflex
• Then do a bladder scan to assess how well the current catheter is draining the bladder – most importan

• Resuscitation: Airway, Breathing, Circulation (ABCs)
  • Make sure they are not hypotensive with the retention
  • Are they febrile?
• Bloods – Urea/electrolytes/creatinine, Full blood count (check Haemoglobin for anaemia)
• Bladder scan >100ml in bladder
  • Do a washout – use a tumo syringe and sterile saline to wash clot out of the bladder
  • If you can easily flush the clot out with the two-way catheter then leave it in
  • If you are having trouble clearing the bladder with a two-way catheter (e.g. pushing in 50-100ml of saline and not able to draw that much saline back out/clots), move onto a three-way catheter

• Three-way catheter is quite specialised with an outflow channel for urine (largest channel), inflow channel for saline irrigation and then the balloon part
• The catheters come in different materials
  • Some are quite rigid and need to be put in with an introducer
  • If you are putting in a three-way catheter be sure it is one you are confident with and won’t cause any damage
  • There are softer and more flexible ones available – but these are less useful for evacuation of blood clots

• Patients with previous radiotherapy or small capacity bladder – there can be an increased the risk of perforation
• Any patient with recent urological surgery – speak to the Urology registrar or consultant before insertion of a three-way catheter or removal of a two-way catheter; especially in recent TURP, or radical prostatectomy

• We rely on three-way catheters in post-operative patients because they stop clots from forming and blocking outflow – they allow the urine to drain freely without obstruction
  • Obstruction can cause sepsis from urine outflow obstruction; and can contribute to poor anastomosis healing
  • Since the bladder is an expansible muscle, healing relies on it being decompressed for a period of time
• The post-op three-way catheters are used for acute bleeding
  • Saline pushing through the catheter can cause local tissue oedema which can compress the vessels and reduce the amount of bleeding
  • This is relevant for radiation cystitis, and cyclophosomide induced haemorrhagic cystitis

• A washout is manually using a syringe to evacuate a clot from the bladder
• Washouts can be done with a two-way or a three-way catheter
• In the Emergency Department it is safer to do a manual washout with a two-way first:
  • Use sterile saline via syringe into the main lumen that drains the urine, ideally in an 18-20Fr catheter
  • Remember that bladder irrigation is a relatively risky procedure, and if you haven’t done a proper washout first, a clot in the bladder can block the outflow of irrigation
    • With water inflow at 60-100 cm of water pressure (depending on the bag height from the patient’s pubic symphysis), you can cause a big intravesical pressure increase, and even rupture if the catheter becomes blocked with a clot
    • Patients will develop severe discomfort unresponsive to analgesia in clot retention
    • Any strain with bladder under extreme pressures could cause a bladder rupture
  • Confirm with a bladder scan to ensure you have done a good washout
    • Less than 30 mL is good
    • 30-50 mL is equivocal
    • More than 50 mL, depends on how high risk the patient is – consider repeating the washout to remove further clots
  • Some patients may need cystoscopic washout if unable to be done manually via catheter

Dependent on the patient:

• Macroscopic haematuria – referral to Urologist
  • Do not put the cause haematuria due to catheter insertion, this may miss an early diagnosis of urinary tract cancer
  • 30% of patients with macroscopic haematuria in the community have a finding of urothelial carcinoma
  • Follow up cystoscopy depends on the underlying risk of the patient for malignancy – higher risk in those that are older, have a heavy smoking history or occupational history
• About 10% of microscopic haematuria has an upper urinary tract cause (renal parenchyma cause)
  • Take a detailed medical history
  • Refer to a renal physician in patients with risk factors such as diabetes, end-organ complications or previous work up for microscopic haematuria 12 months earlier
  • In 60% of patients we are unable to find cause of their haematuria and it is suggested repeating urinalysis in the next 12 months then referring to a renal physician if there is persistent haematuria

• Haematuria is common
• Learn how to do a basic manual washout
• Every patient with macroscopic haematuria should be fully investigated
  • Urine cytology, CT IVP and cystoscopic examination