Gross hematuria has several different etiologies, and as such, the process of working up a patient presenting with bleeding follows an outlined algorithm. The instillation of formalin, a caustic substance that hydrolyzes proteins and coagulates tissues, is a possible treatment option only when patients have failed previous preceding therapeutic steps. In our case, a 69-year-old African-American male presented with an acute episode of gross hematuria that did not resolve following several diagnostic and therapeutic steps. His hospital course was complicated by a steadily dropping hemoglobin, requiring many blood transfusions throughout his care. He was successfully treated with intravesical instillation of formalin following cystoscopy, transurethral resection of the prostate, and cystogram in the operating room. Thoughtful discussion regarding a treatment course in a patient with refractory gross hematuria deserves consideration.