DRIUrology clinical guide
Draft clinical resource — local clinical approval required before intranet publication

Urology Emergency management

Gross haematuria

Assess bleeding severity, relieve clot retention and arrange the correct urgent pathway.

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Visible haematuria flowchart

  1. Visible blood in urineAssess haemodynamic state, pain, urine output, clot passage and anticoagulant/antiplatelet use; obtain FBC, renal function, coagulation and group-and-save as indicated.
  2. Unstable or major ongoing bleeding?Shock, falling haemoglobin, transfusion concern or rapidly increasing bleeding.
  3. Yes — resuscitateED senior + Urgent Urology; activate current major-haemorrhage/reversal pathways when indicated.
    No — assess drainagePalpate/scan the bladder and determine whether urine is draining freely.
  4. Clot retention or poor drainage?Painful distended bladder, inability to void or catheter obstruction.
  5. Yes — Urgent UrologyCompetent large-bore three-way catheterisation and irrigation under the agreed pathway; escalate failure or recurrent blockage.
    No — cause and follow-upTreat proven infection, safety-net and arrange the appropriate haematuria/cancer pathway.

Focused assessment

History

  • Timing, amount, clots and ability to void
  • Pain, dysuria/fever, stones, trauma or recent instrumentation
  • Anticoagulants/antiplatelets and urothelial cancer risk factors

Examination

  • Physiology, perfusion and bleeding elsewhere
  • Abdomen, loins and palpable bladder
  • Catheter patency and urine appearance when already catheterised

Investigations

  • FBC, U&E/creatinine, coagulation and group-and-save
  • Urinalysis and culture when infection is suspected
  • Imaging determined by stability, obstruction, trauma and Urology advice

Immediate assessment

  1. Assess haemodynamic stability, ongoing bleeding, pain, urine output and clot retention.
  2. Check FBC, U&E/creatinine, coagulation screen and group and save; add CRP, urine testing and other investigations according to the presentation.
  3. Review anticoagulants and antiplatelets, but do not stop or reverse them without considering indication, bleeding severity and the current DBTH reversal policy.

Clot retention, instability or significant ongoing bleeding

  • Resuscitate and contact Urology urgently.
  • Experienced staff should insert an appropriate large-bore three-way catheter and commence irrigation when indicated by the agreed local pathway.
  • Escalate failure to drain, ongoing catheter blockage, falling haemoglobin, haemodynamic compromise, sepsis, renal impairment or inability to control pain.
  • Use the current DBTH major-haemorrhage and anticoagulant-reversal policies when criteria are met.

Stable without retention

Investigate and treat a proven UTI appropriately, safety-net, and arrange the correct haematuria pathway. Do not use a single haemoglobin threshold as the sole discharge criterion.

Suspected cancer referral

Use a suspected cancer pathway for adults aged 45 and over with unexplained visible haematuria without UTI, or visible haematuria that persists or recurs after successful UTI treatment, in line with current NICE guidance.