Treatment and Disposition

Treatment of hematuria is directed at the cause. Urinary tract infections should be treated with appropriate antibiotics. Nephrolithiasis should be treated with hydration and analgesics. Systemic diseases should be appropriately treated. Outpatient management and referral for follow-up are appropriate in hemodynamically stable patients without an apparently life-threatening cause. Patients who are discharged should have no or minimal symptoms; be able to tolerate oral fluids, antibiotics, and analgesics as indicated; and have no significant comorbid conditions. Patients should not have significant anemia or acute renal insufficiency.

Patients under 40 years of age should be referred to a primary care physician for repeat urinalysis 1 to 2 weeks after treatment. Persistent hematuria warrants urologic evaluation. Stable patients over 40 otherwise fitting the low-risk profile outlined above can also be evaluated as outpatients, but in these cases cancer is higher on the differential diagnosis list, and referral to a urologist for more immediate outpatient workup is indicated. Children should have pediatric consultation or referral. HIV-positive patients with asymptomatic microscopic hematuria who have a benign urologic history and normal renal function can be safely referred for outpatient follow-up and repeat urinalysis.

Patients with intractable pain, intolerance of oral fluids and medications, significant comorbid illness, evidence of hemodynamic instability, or possibly life-threatening causes of hematuria should be admitted. Patients with suspected or newly diagnosed glomerulonephritis are at high risk of developing complications, such as pulmonary edema, volume overload, azotemia, or hypertensive emergency, and should be admitted with immediate consultation. In pregnant women, hematuria can accompany preeclampsia, pyelonephritis, or obstructing nephrolithiasis, and consultation and admission are indicated.

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