From the Guidelines
The workup for hematuria should begin with a thorough history and physical examination, followed by urinalysis with microscopy to confirm the presence of red blood cells, as recommended by the American College of Radiology 1. Initial laboratory tests should include complete blood count, comprehensive metabolic panel, and urine culture to rule out infection. For patients over 35 years old or those with risk factors (smoking history, chemical exposure, prior urologic disorders), imaging is recommended, typically starting with a renal ultrasound or CT urogram to evaluate the kidneys, ureters, and bladder, as suggested by the American College of Physicians 1. Some key points to consider in the workup of hematuria include:
- Cystoscopy is often necessary, especially for patients with gross hematuria or those over 35, to directly visualize the bladder and urethra for potential tumors or other abnormalities.
- If initial evaluation is negative but hematuria persists, referral to a urologist is appropriate for further specialized assessment.
- For patients with risk factors for glomerular disease (hypertension, proteinuria, abnormal renal function), nephrology consultation should be considered.
- The urgency of the workup depends on whether the hematuria is gross (visible) or microscopic, with gross hematuria warranting more expedited evaluation due to higher risk of malignancy, as noted in the studies 1. This systematic approach helps identify serious underlying conditions like urinary tract malignancies, stones, or glomerular diseases that may present with hematuria.
From the Research
Hematuria Workup
The workup for hematuria typically involves a combination of the following:
- A comprehensive history
- A focused physical examination
- Laboratory studies
- Image-based assessment of the upper urinary tract
- Cystoscopic evaluation of the lower urinary system 2 The goal of the workup is to determine the cause of the hematuria, which can be due to a wide range of conditions, including urinary tract infections, urolithiasis, benign prostatic enlargement, and urologic malignancy 2.
Imaging Studies
Imaging studies play a crucial role in the workup of hematuria. The following imaging studies may be used:
- Computed Tomography (CT) urography: This is a highly sensitive test that can detect small tumors and calculi, and is less susceptible to overlying bowel gas 3.
- Ultrasound: This may be useful in certain cases, particularly in children and pregnant women, but has limited sensitivity for detecting calculi 3.
- Magnetic Resonance Imaging (MRI): This may be useful in certain cases, particularly for detecting small tumors, but has limited sensitivity for detecting calculi 3.
- Excretory urography or intravenous pyelogram: These tests have traditionally been used to evaluate the upper urinary tract, but have largely been replaced by CT urography 3.
CT Urography Protocol
The CT urography protocol typically involves the following phases:
- Unenhanced scan: This is used to evaluate the basic parameters of the kidneys, such as size, shape, position, and outline, as well as to detect calculus disease 4.
- Nephrographic phase: This is used to visualize renal parenchymal diseases, including masses, as well as other abdominal organs 4.
- Excretory phase: This is used to detect urothelial diseases, and includes imaging of the kidneys, ureters, and bladder 4.
Approach to the Patient
The approach to the patient with hematuria should involve a focused history and physical examination, laboratory studies, and diagnostic imaging 5. The patient should be evaluated for life-threatening and benign processes, and the workup should be driven by the patient's stability and the presence of any underlying conditions 5.