From the Guidelines
For a patient with hematuria, a thorough history, physical examination, urinalysis, and serologic testing should be performed prior to any initial imaging, and cystoscopy should be considered in addition to imaging evaluation, especially for patients with gross hematuria or those with risk factors for bladder cancer 1.
Initial Evaluation
The initial evaluation of a patient with hematuria should include:
- Urinalysis: to confirm the presence of red blood cells and assess for other abnormalities
- Urine culture: to rule out urinary tract infection
- Blood tests: complete blood count, renal function tests (creatinine, BUN), and coagulation studies
Imaging Studies
Imaging studies should be considered based on the patient's risk factors and the presence of gross or microscopic hematuria. The following imaging studies may be performed:
- Ultrasound of the kidneys and bladder
- CT urogram or intravenous pyelogram (IVP)
Cystoscopy
Cystoscopy should be considered in patients with gross hematuria or those with risk factors for bladder cancer, such as age >35 years, smoking, or occupational exposure to chemicals 1.
Special Considerations
Patients with suspected urinary tract infection as a cause of microhematuria should have urine cultures performed, preferably before antibiotic therapy, to confirm an infection 1. Patients with a suspected cause of microhematuria, including interstitial cystitis or benign prostatic hyperplasia, should have the appropriate clinical workup before undertaking imaging 1.
High-Value Care Advice
The American College of Physicians recommends that clinicians should refer for further urologic evaluation in all adults with gross hematuria, even if self-limited, and consider urology referral for cystoscopy and imaging in adults with microscopically confirmed hematuria in the absence of some demonstrable benign cause 1.
From the Research
Initial Assessment
The initial assessment of a patient with hematuria should include a careful patient history to identify specific risk factors for urological malignancy 2. The patient history may help to narrow down the range of causes, such as arterial hypertension or a family history of renal disease, which may indicate a renal disease 3.
Diagnostic Approach
The diagnostic approach to hematuria typically begins with a urine dipstick test, which can detect the presence of blood in the urine 4, 3. If the dipstick test is positive, a microscopic urinalysis should be performed to confirm the presence of hematuria 4. The microscopy results can help to differentiate between glomerular and non-glomerular causes of hematuria, with more than 5% acanthocytes in the urine sediment suggesting a glomerular cause 3.
Further Investigations
Further investigations may include:
- Laboratory tests to assess renal function 4
- Imaging tests such as ultrasound, computed tomography urography, or magnetic resonance urography 4, 3
- Cystoscopy, which may be considered in certain cases 4
- Renal biopsy, which may be necessary to confirm the diagnosis of glomerulopathy and develop a treatment plan 3
- Retrograde ureteroscopy, which may be considered based on imaging results 3
Follow-up
Patients with hematuria should be followed up regularly, with repeated urinalyses on an annual basis for two consecutive years recommended if no diagnosis can be established 3. Guidelines also recommend that primary care physicians follow patients with a negative work-up semi-annually for 3 years 4.
Special Considerations
In cases of gross or macroscopic hematuria, the initial evaluation may require only a urine culture, urine calcium-to-creatinine ratio, and renal and bladder sonography, or a very detailed evaluation for renal parenchymal disease, stones, tumors, or anatomic abnormalities 5. Consultation with a pediatric nephrologist, urologist, or both may be necessary in certain cases 5.