Frank Haematuria

You are the urology CT1 asked to see a 75-year-old man who has presented with a 2-day history of frank painless haematuria with clots. How would you proceed?

Example answer introduction

Painless haematuria is a red flag symptom of urinary tract malignancy and I would assess this gentleman immediately. In addition I would bear in mind complications such as clot retention that can complicate this presentation. 

Initial Assessment and Simultaneous Resuscitation

 

On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.

  • Airway 

  • Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns  give high flow oxygen 

  • Circulation

    • Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic

    • IV access - large bore and bloods including CRP

    • Give fluid challenge of 250ml crystalloid solution if evidence of shock 

    • If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol

  • Disability - GCS, pupillary response, blood sugar, temperature

  • Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!

 

During this acute phase state remember to provide constant reassessment

During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, blood glucose, clotting studies, Group and Save and blood and urine cultures if spiking a temperature. 

Focused history​

  • Allergies

  • Medications – anticoagulants, sickle cell 

  • Past medical history – Previous renal tract infections or calculi, sexual history, previous urological procedures, previous occupations, smoking, alcohol, foreign travel 

  • Last meal

  • Events leading up to this point – duration and nature of symptoms haematuria, nausea and vomiting, dysuria, frequency, hesitancy, urgency, nocturia, poor stream

Examination and initial investigations

Abdominal and external genitalia examination:

 

  • Inspect – with chaperone present – abdominal distention, surgical/traumatic scars, external genitalia 

  • Palpate – general abdomen, AAA, renal angle tenderness

  • Digital rectal examination – Prostate enlargement, prostatitis, anal malignancy

 

 

 

 

I would then request further investigations: 

 

  • Urine dip – looking for blood, leukocytes, nitrites, glucose, ketones

  • Send urine for microscopy and culture

  • Bladder scan 

  • Depending on my findings he may require a CT kidneys, ureters and bladder (KUB) and cystoscopy but I would discuss this with the registrar first.

Example questions to progress the station

Q1 He is clinically well but continues to pass frank haematuria with some clots. He has 600mls in his bladder. His inflammatory markers and renal function are normal. How would you proceed? 

Q1 Answer

He is in acute bladder retention likely due to clots. I would site a urinary catheter and perform a bladder washout and inform the urology registrar to review for further imaging (CT KUB) and a cystoscopy. 

 

  • Keep nil-by-mouth

  • Maintenance IV fluids

  • Prep for theatre 

  • Keep patient and any relatives informed

  • Document, document, document!!!

Escalation
Painless haematuria would usually present in an outpatient clinic setting. Its important to say that you would escalate because in this situation the question is:
Is this malignancy?
In cases of clot retention one must liaise closely with the urology Regestrar as these patients may be quite sick and you may not have the expertise to place a 3-way catheter and set up bladder irrigation. 
Useful Resources

Update on interventional uroradiology.

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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