Haematuria and clot retention
Clots and can't pass urine: three-way catheter and washout. Anticoagulants don't explain haematuria — it still needs investigating.
A 68-year-old smoker has painless frank haematuria. Now he can't pass urine and has severe lower abdominal pain. His bladder is palpable. Pulse 104, BP 142/86, Hb 10.8 g/dL. He takes aspirin.
A 25-year-old has had cola-coloured urine since a sore throat 2 days ago.
What do you do for the first man tonight, and why is the second a different problem?
- Is the patient stable?Pulse, BP, Hb, group and save.
- Can they pass urine?Bladder scan. Clot retention needs a three-way catheter.
- Clot retention20–22 Fr three-way catheter, washout with a bladder syringe, then continuous irrigation.
- BloodsFBC, U&E, clotting, group and save, urine culture.
- Review medicinesAnticoagulants and antiplatelets, balance bleeding against clot risk with a senior.
- Frank painless haematuria over 45 yearsUrology referral for cystoscopy and imaging.
- Microscopic with protein, high BP or kidney injuryThink kidney (glomerular) cause.
- Clot retention not cleared by washout
- Shock or falling Hb
- Rising creatinine
- Haematuria with fever and loin pain (infected obstruction)
- Irrigation in but not out
- Bladder cancer
- Kidney cancer
- Infected obstructed kidney
- Glomerulonephritis
- Anticoagulant overdose
- Trauma
- Schistosomiasis in endemic areas
| Three-way catheter | 20–22 Fr for clot retention |
| Irrigation | Run fast enough to keep the output light pink (rosé) |
| Input minus output | Track hourly to detect blockage |
| Hb below 7 g/dL | Usually transfuse (higher in heart disease) |
| Glomerular clues | Red cell casts, protein, dysmorphic red cells, high BP, rising creatinine |
Check every dose against a current drug reference and your hospital protocol.
On this page
Causes
| Group | Examples |
|---|---|
| Bladder | Cancer, infection, stones, radiation cystitis, schistosomiasis |
| Kidney | Cancer, stones, trauma, glomerulonephritis, polycystic kidneys |
| Prostate | Enlarged prostate (vascular), cancer, after procedures |
| Ureter | Stones, cancer |
| Urethra | Trauma, catheter injury |
| General | Anticoagulants, bleeding disorders, sickle cell |
Not haematuria: beetroot, rifampicin, myoglobin (rhabdomyolysis), haemoglobin, menstruation.
Visible or non-visible? Painful or painless?
Bladder cancer until proven otherwise: urology
Stone or kidney cause: CT KUB
Infection: culture, treat, recheck after
Glomerular: nephrology
Clot retention
- AnalgesiaPain is severe.
- Three-way catheter20–22 Fr. Lubricate well.
- Washout50 mL bladder syringe with saline: push and pull until the clots clear.
- Continuous irrigationSaline through the inflow port, fast enough to keep the output light pink.
- MonitorHourly input and output. If input exceeds output, the catheter is blocked: stop irrigation, wash out.
- Not clearingUrology for cystoscopy and clot evacuation.
Investigations
| Test | Why |
|---|---|
| Urine dipstick and culture | Infection, protein |
| Urine microscopy | Red cell casts (glomerular) |
| FBC, U&E, clotting, group and save | Blood loss, kidney function |
| Ultrasound kidneys and bladder | Masses, obstruction, residual |
| CT urogram | Visible haematuria work-up (upper tract) |
| CT KUB | Stones |
| Cystoscopy | Bladder cancer (gold standard) |
| PSA | After counselling, in men with symptoms |
Treatment
See catheterisation and urinary retention.
Special situations
- Anticoagulated: haematuria still needs investigating; anticoagulants unmask, they don't cause, most bleeding lesions.
- Schistosomiasis: terminal haematuria in people from endemic areas; associated with squamous bladder cancer.
- Trauma: CT; urethral injury if blood at the meatus.
- Young with haematuria after infection: IgA nephropathy (days after) or post-streptococcal glomerulonephritis (1–3 weeks after).
Common mistakes
Frequently asked questions
What causes painless visible haematuria?
Bladder cancer is the main cause to exclude, especially in smokers over 45. Kidney cancer, prostate enlargement and infection are others.
How do you manage clot retention?
A 20–22 Fr three-way catheter, bladder washout, then continuous irrigation with saline, tracking input and output.
Does haematuria on warfarin need investigation?
Yes. Anticoagulants usually unmask an underlying lesion.
What suggests a kidney (glomerular) cause of haematuria?
Protein in the urine, red cell casts, high blood pressure and a rising creatinine.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A man has visible haematuria and his catheter stops draining; the bladder is distended. What is needed?
Answer: Three-way catheter and bladder washout. Clot retention needs washout and continuous irrigation.
- Remove the catheter and wait: No.
- Suprapubic catheter immediately: Not first.
- Furosemide: No.
- Increase fluids only: Clots block the catheter.
2. A 70-year-old smoker has painless visible haematuria with no infection. What is most important?
Answer: Urgent cystoscopy and imaging. Painless visible haematuria over 45 is a red flag for bladder cancer.
- Antibiotics and reassure: Cancer must be excluded.
- Drink more water: No.
- Repeat urine dip in 6 months: Delay.
- PSA only: Not enough.
3. Which infection associated with bladder cancer should be considered in someone from an endemic area?
Answer: Schistosomiasis. Schistosoma haematobium is linked to squamous cell carcinoma of the bladder.
- Typhoid: No.
- Hepatitis B: No.
- Malaria: No.
- Brucella: No.
4. A 58-year-old smoker has painless visible haematuria with clots. Urine culture is negative. What are the key investigations?
Answer: Flexible cystoscopy + CT urogram. Painless visible haematuria in adults (especially > 40 or smokers) needs evaluation of the lower tract (flexible cystoscopy — bladder cancer) and upper tract (CT urography — RCC, upper tract urothelial carcinoma, stones), plus renal function and BP. Urine cytology is an adjunct only. Clot retention may need a three-way catheter and bladder washout.
- Urine cytology alone: Cytology alone is insensitive.
- PSA and reassure: PSA does not exclude bladder or kidney cancer.
- Antibiotics and repeat dipstick: Antibiotics delay cancer diagnosis.
5. A man who grew up in an area endemic for Schistosoma haematobium develops painless haematuria; cystoscopy biopsy shows keratinising carcinoma. What is the histology?
Answer: Squamous cell carcinoma. Bladder cancer: urothelial carcinoma (> 90% globally — smoking, aromatic amines (dyes, rubber), cyclophosphamide, pioglitazone). Squamous cell carcinoma: chronic irritation — schistosomiasis (Egypt, Africa), long-term catheters, bladder stones, chronic infection. Adenocarcinoma: urachal remnant (dome), bladder exstrophy. Painless haematuria → cystoscopy + CT urogram. Non-muscle-invasive: TURBT + intravesical BCG/mitomycin; muscle-invasive: cystectomy or chemoradiation.
- Urothelial (transitional) carcinoma: Urothelial carcinoma is the commonest overall, but schistosomiasis causes SCC.
- Adenocarcinoma: Adenocarcinoma is linked with the urachus or exstrophy.
- Small cell carcinoma: Small cell carcinoma is rare.
6. A 55-year-old man who smokes has fever, weight loss, haematuria, a loin mass and a high haemoglobin. What is the most likely diagnosis?
Answer: Renal cell carcinoma. Renal cell carcinoma (clear cell type, chromosome 3p and VHL loss) can cause haematuria, loin pain and a mass, plus fever and weight loss. Paraneoplastic effects include polycythaemia (EPO), hypercalcaemia (PTHrP) and hypertension (renin). It tends to invade the renal vein. Smoking is a major risk factor.
- Transitional cell carcinoma of the bladder: Painless haematuria but no loin mass or polycythaemia.
- Wilms tumour: A childhood tumour.
- Polycystic kidney disease: Bilateral masses with hypertension; usually no fever or weight loss.
- Renal tuberculosis: Sterile pyuria; no polycythaemia.
7. A young man has painless visible haematuria 1–2 days after an upper respiratory infection. Renal biopsy shows mesangial IgA deposits. What is the diagnosis?
Answer: IgA nephropathy (Berger disease). IgA nephropathy is the commonest primary glomerulonephritis worldwide: episodic haematuria within 1–2 days (synpharyngitic) of a mucosal infection, with mesangial IgA deposits. Post-streptococcal GN appears 1–3 weeks after infection with low C3, subepithelial humps and nephritic syndrome. IgA vasculitis (HSP) is the systemic counterpart.
- Post-streptococcal glomerulonephritis: Delay of 1–3 weeks; low C3.
- Minimal change disease: Nephrotic, children, no deposits on light microscopy.
- Goodpasture syndrome: Anti-GBM, linear IgG, haemoptysis.
- Alport syndrome: Hereditary; deafness and eye changes.
References and dose sources
- NICE NG12
- BAUS
- NICE NG39
- Morphine dosing: Drugs.com: Morphine dosage (see also our morphine dose page)
- Sodium chloride (normal saline, 3% saline) dosing: Drugs.com: Sodium chloride dosage (see also our sodium chloride (normal saline, 3% saline) dose page)
- Nitrofurantoin dosing: Drugs.com: Nitrofurantoin dosage (see also our nitrofurantoin dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.