Macroscopic haematuria post fall

Question 1

A 63 year old man presents with macroscopic haematuria after a fall off a ladder. Can you outline your management?

Answer 1

Impression
Macroscopic haematuria post fall may indicate a kidney laceration, or trauma to other anatomical structures of he genitourinary tract (urethral, penile, bladder, ureteral). The major concern is for the development of a large retroperitoneal bleed, and for other intra-abdominal traumatic pathology:

DDX

• ureters, bladder, urethral injury
• consider splenic laceration
• low likelihood, but consider malignancy.
• other causes of haematuria: nephrolithiasis

Goals

• conduct initial assessment to rule out HD instability
• investigate source of bleeding with CT abdo, initiate appropriate acute management of the bleeding and treat any injuries.

Question 2

Macroscopic haematuria - Assessment

Answer 2

Assessment

A to E to ensure HD stable, also rule out

Question 3

Macroscopic haematuria - History

Answer 3

History

• PC: trauma, MOI, how high etc, onset of haematuria compared to injury, degree of haematuria (frank vs straw-coloured, flank/renal angle pain, other abdo tenderness
• sx: any prior haematuria? weight loss/night sweats/fevers
• AMPLE

Question 4

Macroscopic haematuria - Examination

Answer 4

Examination

• General appearance + vitals
• Abdo exam: grey-turners/cullens sign (Retroperitoneal bleeds), tenderness/guarding, shifting dullness, renal angle tenderness
• External genitalia assessment: blood at the meatus (urethral trauma) is CI to catheterisation
• Systems review, secondary survey (other injuries sustained)

Question 5

Macroscopic haematuria - Investigations

Answer 5

Investigations
Key/diagnostic
- Trauma series X-Ray
- eFAST for free abdominal fluid
- CT abdo, additional renal-phase contrast (Arterial phase contrast, then delayed phase for ?leaking urine)

• Bedside: urinalysis,
• Bloods: coags, FBC, UEC (pre-contrast), LFT, G+H/xmatch, other pre-op bloods
• Other imaging: Bladder scan

Question 6

Macroscopic haematuria - Management

Answer 6

Management
- urology consult/interventional radiology

Supportive

• stabilise with IV fluids
• blood transfusion if indicated based on HD stability
• reversal of any anticoagulation
• analgesia, antiemetics, etc
• regular obs
• catheterisation (3-way catheter)

Definitive

• IR embolisation if bleeding artery
• Surgical: complex reconstructive surgery, partial or complete nephrectomy, urethral splinting/ureteric setting if laceration, other surgical options as directed by urology.