Urinary Haemorrhage

Appropriate assessment to identify cause and severity of symptoms

Explanation to patient and family

Correct reversible factors

Consider disease-specific palliative therapy

Appropriate assessment to identify cause and severity of symptoms 

• Haematuria is a frequent presentation in urological disease and should be explored as abnormal, ranging from microscopic haematuria, detected by urinalysis, to clearly visible frank haematuria or passage of clots. Identify the cause: 
  • Tumour: renal, ureteric, bladder, prostate, 
  • UTI 
  • Drug-induced: Warfarin & NSAIDS causing bleeding tendency; Cyclophosphamide causing haemorrhagic cystitis 

Explanation to patient and family 

Patients and families alike are often perturbed by the discolouration of urine, thinking that red urine necessarily means haemorrhaging. Discuss the relevant cause and relieve the related anxiety, as common changes relate to the following: 

• Red/pink: haematuria, beetroot, rhubarb, danthron 
• Dark: Metronidazole 

Purple Urinary Bag: caused by the breakdown of dietary triptophan metabolites by bacteria in the urine. 

Correct reversible factors 

Complete evacuation of clots (irrigation with water or saline through large bore urethral catheter).

Cystourethroscopy for diagnosis and cautery if patient fit enough.

If haemorrhage is mild it may be appropriate to reassure patient and family alike and treat the infection if needed, reporting back if haemorrhage persists or increases. 

More severe haemorrhage: consider referral to assess whether it is appropriate to use Tranexamic acid 1 g qid po or IVI recognising the risk of clot formation and obstruction. 

Severe haemorrhage: 

• Cauterisation 
• Arterial embolisation 
• This may be a terminal event – stabilise – blood transfusion if needed 

Other: Bladder instillations and irrigation 

• Alum 50ml 1% instilled through a catheter & retained for 1 hour – repeat bd as needed 

Clot retention

Evacuate clots as a non-distended bladder bleeds far less. A large bore (22Fr) catheter to be inserted. It is necessary for a urologist to assist if a 3-lumen catheter is to be inserted. Cystoscopic bladder irrigations may be needed. Percutaneous insertion of a suprapubic catheter is contraindicated – the lumen is too small for irrigation and seeding of bladder tumour may occur. 

Irrigate with: 

Consider disease-specific palliative therapy 

• Palliative radiotherapy 
• Involve the urologist early in managing this problem