From the Guidelines
The workup of gross hematuria should begin with a thorough history and physical examination, followed by urinalysis with microscopy to confirm the presence of red blood cells, and all patients with gross hematuria should have a full urologic workup, including CT urography and cystoscopy, as recommended by the American College of Radiology 1. The initial evaluation should also include complete blood count, comprehensive metabolic panel, and coagulation studies. Urine culture should be obtained to rule out infection.
- Key points to consider in the workup of gross hematuria include:
- Thorough history and physical examination
- Urinalysis with microscopy to confirm the presence of red blood cells
- Initial laboratory tests, including complete blood count, comprehensive metabolic panel, and coagulation studies
- Urine culture to rule out infection
- Imaging studies, with CT urography being the preferred initial imaging modality
- Cystoscopy to evaluate the bladder and urethra directly
- Consideration of risk factors, such as smoking history, occupational exposures, or prior pelvic radiation, which may necessitate a complete urologic evaluation The diagnostic accuracy of cystoscopy for detecting bladder cancer in adults presenting with hematuria is high, with sensitivities ranging from 87% to 100% and specificity ranging from 64% to 100%, as reported in a systematic review from the European Association of Urology Guidelines Office 1.
- The American College of Physicians also provides guidance on the evaluation of hematuria, recommending that clinicians refer all adults with gross hematuria for further urologic evaluation, even if self-limited, and consider urology referral for cystoscopy and imaging in adults with microscopically confirmed hematuria in the absence of a demonstrable benign cause 1. The urgency of the workup depends on the clinical presentation, with patients who have clot retention, significant anemia, or hemodynamic instability requiring immediate attention.
- Patients on anticoagulation therapy should still undergo a complete evaluation, as anticoagulation may unmask underlying pathology rather than being the primary cause. Overall, a comprehensive approach to the workup of gross hematuria is necessary to promptly diagnose and treat underlying conditions, including malignancy.
From the Research
Workup of Gross Hematuria
The workup of gross hematuria involves a thorough history and physical to determine potential causes and assess risk factors for malignancy 2.
- A focused history and physical, including laboratory studies and diagnostic imaging, drive the workup 3.
- The cause of gross hematuria often originates in the genitourinary tract, and patients can be discharged with close outpatient follow-up if they remain stable 3.
- However, gross hematuria, especially in the elderly, frequently signals the presence of urologic malignancy, with a risk of malignancy greater than 10% 2.
- Prompt urologic referral is recommended for patients with gross hematuria due to the high risk of malignancy 2.
- The workup may also occasionally yield a nongenitourinary tract cause, which may require emergent management 3.
Diagnostic Approach
- A general surgeon or clinician should have a urologic framework of thinking to best manage a patient with hematuria, including knowledge of the pathophysiology, anatomy, etiologies, workup, and treatments of hematuria 4.
- Common causes of hematuria that may be encountered include trauma, urinary tract infection, urolithiasis, and malignancy 4.
- The clinician should be aware of the difficult to manage clinical situation of clot urinary retention in patients with hematuria 4.