Introduction

If a patient is experiencing frank haematuria with the passage of clots, the most immediate risk is of clot retention, whichmay be difficult to resolve. It is extremely rare for haematuria to present to such a degree that it becomes acutely life threatening from exsanguination, although those on anticoagulant medication are at more risk. Gross haematuria is significant in the setting of genitourinary trauma.

Definition and classification

There is no absolute definition for massive haematuria. Haematuria is divided into microscopic and macroscopic (gross/frank) and then further divided into painless or painful. Initial painless macroscopic haematuria may become painful with the passage of clots or impending clot retention.

History

A good history and examination will indicate the likely source of haematuria. Initial simple classifications, as above, will include/exclude multiple causes. It is always important to take a full urological history including:

1. ▪ Previous urological procedures

2. ▪ History of UTIs/STDs

3. ▪ Lower urinary tract symptoms (LUTS)

4. ▪ Risk factors for urinary tract malignancies (smoking/occupational risks/family history)

5. ▪ Preceding trauma.

A thorough past medical and drug history will also highlight diagnosis and treatments associated with haematuria, such as anticoagulant/antiplatelet agents.

Examination

In the presence of extreme haematuria, the patient should be resuscitated with regards to their airway, breathing and circulation. This may well be in the setting of advanced trauma life support (ATLS) if trauma has been a precipitating cause. Once intravenousaccess and fluid resuscitation have been initiated, examination can be directed towards identifying a cause for haematuria. A full abdominal system examination, including external genitalia in both men and women and digital rectal examination (DRE) in men is thus performed.