From the Guidelines
The outpatient workup for hematuria should begin with a thorough history and physical examination, followed by urinalysis confirmation of blood in the urine, and initial laboratory tests including complete blood count, comprehensive metabolic panel, and urine culture to rule out infection, as recommended by the American College of Radiology 1.
Initial Evaluation
The initial evaluation of hematuria should include:
- A thorough history and physical examination to identify potential causes of hematuria
- Urinalysis to confirm the presence of blood in the urine
- Initial laboratory tests, including complete blood count, comprehensive metabolic panel, and urine culture to rule out infection
Imaging Studies
Imaging studies are essential in the evaluation of hematuria, typically starting with renal ultrasound to evaluate the kidneys and bladder.
- For patients over 35 or with risk factors for urological malignancy (smoking history, chemical exposure, prior pelvic radiation), a CT urogram is recommended to better visualize the entire urinary tract 1.
Specialized Tests
Additional specialized tests may include:
- Urine cytology to detect malignant cells
- 24-hour urine collection to assess for nephrological causes if glomerular bleeding is suspected
- Cystoscopy is indicated for adults with microscopic hematuria and all patients with gross hematuria to directly examine the bladder mucosa for lesions 1.
Follow-up
Follow-up should occur within 4-6 weeks of initial evaluation with repeat urinalysis.
- If hematuria persists despite negative initial workup, referral to urology or nephrology is warranted.
- For resolved hematuria with negative workup, annual urinalysis for 2 years is recommended 1. This comprehensive approach is necessary because hematuria can signal serious conditions including malignancy, urolithiasis, or glomerular disease, and early detection significantly improves outcomes, particularly for urological cancers.
From the Research
Outpatient Workup for Hematuria
- The workup for hematuria includes a thorough history and physical to determine potential causes and assess risk factors for malignancy 2.
- Laboratory tests, such as urinalysis, urine culture, and serum creatinine, are used to rule out intrinsic renal disease 3, 4.
- Imaging of the urinary tract, including renal ultrasound and intravenous urogram, is also part of the workup 3, 4.
- Cystoscopy is recommended for patients with gross hematuria and for patients with microscopic hematuria who are at high risk for malignancy 5, 4.
Follow-up for Hematuria
- Patients with hematuria should be followed up to monitor for resolution of symptoms and to detect any potential malignancies 2, 3.
- The American Urological Association recommends complete urologic evaluation for all patients with microscopic hematuria who are over 40 years of age, and younger patients with a history suspicious for urologic disease 4.
- Patients with a positive urine culture should not be excluded from rapid evaluation hematuria protocols, as the presence of a urinary tract infection does not decrease the likelihood of having a urologic malignancy diagnosed 3.
Special Considerations
- Patients with gross hematuria have a higher risk of malignancy (>10%) and should be referred to a urologist promptly 2.
- Patients with microscopic hematuria who have a history of cigarette use, occupational exposure, or chronic phenacetin use should undergo complete upper and lower urinary tract evaluation 4.
- The presence of a urinary tract infection does not exclude the possibility of a urologic malignancy, and patients with hematuria and a positive urine culture should be evaluated promptly 3.