Intravesical tranexamic acid for gross hematuria in the emergency department: a prospective cohort study

Gross hematuria is a common emergency department(ED) presentation that is often managed with continuous bladder irrigation(CBI). Intravesical tranexamic acid (TXA) has been proposed as an adjunct, but supporting evidence is limited. We evaluated whether adding intravesical TXA to CBI improves the rate of ED discharge in patients with gross hematuria. We conducted a prospective, single-center cohort study in an academic ED between June and December 2025. Adults presenting with gross hematuria and a hematuria grading scale (HGS) score ≥ 6 were included.Treatment was assigned by calendar date rather than randomization: CBI alone on odd-numbered days and CBI plus a single 1 g intravesical TXA instillation(15-minute dwell) on even-numbered days. The primary outcome was successful hemostasis permitting ED discharge (HGS ≤ 3, no residual clots, no urology-wardadmission). Among discharged patients, secondary outcomes were irrigation fluid volume, ED length of stay, and one-week revisit. Effect estimates were reported as odds ratios (OR) or median differences with 95% confidence intervals (CI). Of 94 patients, 57 received CBI alone and 37received CBI+TXA; baseline characteristics were comparable. ED discharge was achieved in 45/57 (79%) versus 31/37 (84%) (OR 1.38, 95% CI 0.47–4.06; p = 0.560). Among the 76 discharged patients, there were no significant differences in irrigation fluid volume (2750 vs 2250 mL; p = 0.106), length ofstay (350 vs 365 min; p = 0.828), or revisit rates (22.2% vs 16.1%; OR 0.67, 95%CI 0.21–2.21; p = 0.512). In univariable analysis, a recurrent hematuria episode was associated with lower odds of discharge (OR 0.30, 95% CI 0.10–0.91; p = 0.028), whereas TXA was not. No systemic adverse events occurred. Adding intravesical TXA to CBI was not associated with a statistically significant difference in ED discharge or secondary outcomes. Given the non-randomized design, limited sample size, and wide confidence intervals, these findings indicate a lack of demonstrated benefit rather than proof of no effect; larger, adequately powered randomized trials are warranted.