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Please note: This page is intended for healthcare professionals only. It is designed as a general educational guide and does not replace local guidance, senior clinical advice, or individual clinical judgement. Patients should not use this page as medical advice and should seek advice from an appropriate healthcare professional.

Visible Haematuria: Emergency Management

Visible haematuria is one of the most common acute presentations and reasons for referral to the on-call urology team. Some cases may require admission and urological input on the ward, while others may be able to be reassured and managed in the outpatient setting.

This section will talk about significant visible haematuria that requires inpatient care.

 

Immediate Priorities

1Assess:

  • Haemodynamic stability (A-E assessment)
  • A full history
  • Determine:
    • Ability to pass urine
    • Presence of clots
    • Evidence of sepsis
    • Recent urological surgery/procedure
    • Anticoagulant or antiplatelet use

2Examine:

  • Abdomen
  • External genitalia
  • Digital rectal examination (in men), bimanual exam in female patients
  • Visual inspection of the urine (important!)

Escalate urgently if:

  • ✓Clot retention
  • ✓Haemodynamic instability
  • ✓Significant Hb drop
  • ✓Urosepsis
  • ✓AKI / obstructed kidney
  • ✓Significant bleeding after urological surgery

When is haematuria considered "significant" for admission?

Non-visible haematuria = doesn’t require hospital admission.

  • If incidental – repeat dipstick in 4-6 weeks, refer to Urology as per NICE guidance.

Visible haematuria = depends on the colour

  • Light / pink / see-through = doesn’t require acute treatment; can be discharged with safety netting advice and investigated as outpatient
  • Brown / coca-cola = old haematuria
  • Maroon / merlot / fresh / clots = significant, and requires acute treatment – read further HERE
Grades of visible haematuria
Grades of visible haematuria
 

Investigations

  • Post void bladder scan – to determine if retention
  • Consider urine dipstick testing +/- urine culture
  • Blood tests:
    • FBC, U&E, CRP
    • Clotting
    • Group and save
  • Imaging of the upper tracts - recommended for all patients with visible hematuria
    • If this can be done as an inpatient it can be helpful but can safely be performed as an OP scan under cancer pathway and shouldn’t typically delay the discharge.
    • This is usually a CT Urogram, but in certain cases an USKUB is sufficient.
 

Clot Retention

Typically presents with severe suprapubic pain associated with visible haematuria and clots in the urine. The clots that form in the bladder fail to be expelled, prevent the voiding of urine and so result in retention. Patients presenting with clot retention will require an admission under urology.

 

Management

1Insert large-bore 3-way catheter (20–22Ch)

2Manual bladder washout

3Evacuate all clots

4Commence CBI if ongoing bleeding (see how it’s done HERE)

5Monitor urine output and colour

6Treat underlying cause

7Transfuse blood as needed

8Consider temporary cessation of anticoagulants or antiplatelets.

  • Balance bleeding risk against thromboembolic risk
  • Decisions should be individualised and discussed with a senior clinician

9Some patient will require going to theatre for GA rigid cystoscopy + washout +/- cystodiathermy

Important:

CBI does not remove established clots.

It is important to perform bladder washout before starting bladder irrigation. Otherwise, it may result in catheter blockage while active fluid is being instilled into the bladder. This can lead to bladder overdistension, patient discomfort and, in severe cases, bladder perforation.

Who might require going to theatre?
  • Recurrent catheter blockage
  • Persistent large clot burden
  • Worsening pain
  • Inability to maintain catheter drainage
  • Ongoing Hb drop

If you are worried at any point about a patient with bleeding = escalate to Urology SpR / consultant + keep patient NBM

 

Take Home Messages

  • Most visible haematuria does not require admission.
  • Clot retention always requires urgent management.
  • Washout first, CBI second.
  • Persistent bleeding despite washouts and CBI may require theatre.
  • Significant haematuria can occur even with a normal Hb initially.
  • If in doubt, discuss with the urology registrar.

References

  1. NICE Guideline [NG12]. Suspected cancer: recognition and referral. 2015 (updated 2023).
  2. BAUS & The Renal Association. Joint Consensus Statement on the Initial Assessment of Haematuria. 2008.
  3. BAUS Consensus Document for the Management of Visible Haematuria
  4. IDENTIFY Risk Calculator – BURST Urology: HERE
  5. Khadhouri S, et al. The IDENTIFY Study: Developing a risk calculator for urinary tract cancer. Trends in Urology