The initially voided urine may provide clues as to the location of injury. When possible, at least two specimens (initial stream and terminal stream) should be obtained. Initial hematuria suggests injury to the distal system (i.e., urethra or prostate). Terminal hematuria suggests bladder neck injury. Continuous hematuria suggests upper renal system (bladder, ureter, or kidney) injury.
Many studies have demonstrated that, in adult patients with blunt trauma, the degree of hematuria does not correspond to the degree of injury. Gross hematuria may be seen with relatively minor renal contusions, whereas microscopic hematuria (or even no hematuria) may be seen in renovascular injuries. However, in the absence of significant hemodynamic compromise, isolated microscopic hematuria is unlikely to represent significant blunt injury. While there is no clinically validated or generally accepted upper limit of microscopic hematuria beyond which imaging is done, many physicians image patients where the degree of microscopic hematuria is 350 RBCs/hpf. A review of several major studies addressing this question concluded that isolated microscopic hematuria indicates significant injury in about 1 in 500 patients with such a finding.3 Thus, the current consensus is that adult patients with isolated microscopic hematuria do not require further imaging studies. There are three exceptions. When the mechanism of trauma involves rapid deceleration, renal pedicle injuries may ensue but can present with minimal (or even no) hematuria. Also, hematuria in a patient with even transient hypotension should not be considered an isolated finding. Finally, microscopic hematuria may be a significant finding in children, as detailed later in the text.
All patients in whom microscopic hematuria is found with concurrent nonrenal injuires and those with hemodynamic instability should have a diagnostic imaging study, as discussed below. In such patients, computed tomography (CT) is often impractical. A "one-shot" intravenous pyelogram (IVP) can be obtained in the operating room.
Gross hematuria may occur from injury virtually anywhere in the renal tract. The finding of gross hematuria mandates a diagnostic imaging study that is chosen based on other findings (Ta.ble 254-4.). For example, in the presence of pelvic fractures, gross hematuria should raise the possibility of bladder or urethral injury. Almost 95 percent of bladder injuries are associated with gross hematuria.
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