Initial Evaluation of Gross Hematuria in the Emergency Department

Marc Bjurlin*, Phillip C Ginsberg*, Michael J Metro, Richard C Harkaway
Albert Einstein Medical Center, Philadelphia, PA

Introduction:
To propose an initial diagnostic algorithm for patients presenting to the Emergency Department (ED) with gross painless hematuria.
Methods:
A retrospective analysis of 162 patients presenting to our ED between 1995 and 2003 with gross painless hematuria and no evidence of UTI was performed. We excluded 19 patients who recently underwent genitourinary surgery, had genitourinary trauma, or had indwelling catheters. We also excluded 26 patients lost to follow-up without outpatient evaluation. Initial evaluation began with a noncontrast “stone search” CT scan with contrast given when no stone was detected. All patients were then referred to a urologist where they underwent further radiologic evaluation (U/S, IVP, or RPG) and cystoscopy.
Results:
117 patients were evaluated. 31 were diagnosed with urinary calculi by nonenhanced CT. 86 received contrast enhanced CT scans. 21 had some other possible cause of bleeding detected and 64 still had no diagnoses. All 64 patients without CT diagnosis had IVP or RPG and 30 also had diagnostic ultrasonography. Eight abnormalities were found on IVP or RPG including two stones missed on CT. Ultrasonography added nothing once CT had been performed. Cystoscopy was performed on all 117 patients and 29 cases of lower tract pathology were detected.
Conclusions:
CT scan should be the initial study for gross painless hematuria in the ED.

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