From the Guidelines
Hematuria in long-term care (LTC) patients should be evaluated using the AUA/SUFU Microhematuria Risk Stratification System 2025 to determine the risk of malignancy and guide further management. Initial management includes obtaining a thorough history, physical examination, urinalysis, and urine culture 1. Common causes in elderly LTC patients include urinary tract infections (UTIs), medication effects (especially anticoagulants like warfarin, apixaban, or aspirin), kidney stones, benign prostatic hyperplasia in men, and potentially bladder or kidney cancer. For UTIs, empiric antibiotic therapy such as nitrofurantoin 100mg twice daily for 7 days or trimethoprim-sulfamethoxazole 160/800mg twice daily for 7 days may be appropriate while awaiting culture results.
Key Considerations
- Patients with gross hematuria, persistent microscopic hematuria, or risk factors for malignancy should be referred for urological evaluation, which may include cystoscopy and upper tract imaging 1.
- Medication review is essential to identify potential causative agents.
- Adequate hydration should be encouraged to prevent clot formation and urinary retention.
- The urgency of evaluation depends on the severity of hematuria, associated symptoms, and patient's overall condition.
Risk Stratification
The AUA/SUFU Microhematuria Risk Stratification System 2025 categorizes patients into low, intermediate, and high risk of malignancy based on factors such as degree of hematuria, age, smoking history, and presence of additional risk factors for urothelial cancer 1.
Management Approach
- Low-risk patients may not require further evaluation, while intermediate and high-risk patients should undergo further testing, including cystoscopy and upper tract imaging.
- Patients with a history of gross hematuria or persistent microscopic hematuria should be referred for urological evaluation regardless of their risk category.
- Hematuria warrants attention because it can be the first sign of urological malignancies, which have higher prevalence in the elderly population, and early detection improves outcomes 1.
From the Research
Hematuria in LTC Patients
- Hematuria is a common condition that can be classified as either gross or microscopic 2
- The risk of malignancy with gross hematuria is greater than 10%, and prompt urologic referral is recommended 2
- Microscopic hematuria most commonly has benign causes, such as urinary tract infection, benign prostatic hyperplasia, and urinary calculi 2
- Urinary tract infections are among the most common reasons for an outpatient visit and antibiotic use in adult populations 3
- The diagnosis and management of hematuria can be challenging, especially in complex patients such as those in long-term care (LTC) settings 4
Causes and Risk Factors
- Common causes of hematuria include trauma, urinary tract infection, urolithiasis, and malignancy 4
- Risk factors for ciprofloxacin or multidrug resistance in primary care urine specimens are not well defined, but may include prior fluoroquinolone use, prior ciprofloxacin resistance, and diabetes mellitus 5
- Birth outside the U.S.A., prior trimethoprim/sulfamethoxazole resistance, and diabetes mellitus are associated with trimethoprim/sulfamethoxazole resistance 5
Diagnosis and Management
- A thorough history and physical examination are essential in determining the potential causes and assessing risk factors for malignancy 2
- Laboratory tests, imaging of the urinary tract, and referral to nephrology and urology subspecialists may be necessary to rule out intrinsic renal disease and other causes of hematuria 2
- Immediate antimicrobial therapy is recommended for acute cystitis, rather than delayed treatment or symptom management with ibuprofen alone 3
- The choice of empirical antibiotic regimen should be individualized based on risk factors for resistance and regimen tolerability 3, 5