From the Guidelines
The appropriate Review of Systems (ROS), diagnostic approach, and treatment for a 50-year-old male presenting with microscopic hematuria is to first rule out benign causes and then consider urology referral for cystoscopy and imaging, as the risk of underlying cancer, although low, cannot be ignored 1.
Review of Systems (ROS)
A thorough history and physical examination should be performed to identify potential causes of hematuria, including:
- Medical history: previous urologic diseases, pelvic irradiation, chronic urinary tract infections, and exposure to carcinogenic agents
- Medications: anticoagulant therapy, which does not alter the urologic evaluation of microhematuria 1
- Family history: urologic cancers
- Symptoms: irritative voiding symptoms, flank pain, or renal colic
Diagnostic Approach
- Urinalysis: to confirm the presence of hematuria and rule out infection or other abnormalities
- Serologic testing: to evaluate for renal parenchymal disease
- Cystoscopy: to visualize the bladder and urethra for tumors or other abnormalities
- Imaging: CT scan of the abdomen and pelvis, or other imaging modalities, to evaluate the upper urinary tract
Treatment
Treatment will depend on the underlying cause of the hematuria. If a benign cause is identified, treatment will focus on managing that condition. If no cause is found, or if cancer is suspected, further evaluation and treatment will be guided by urologic consultation and may include:
- Transurethral resection of the bladder tumor (TURBT): to confirm the diagnosis and determine the extent of disease
- Intravenous pyelogram (IVP), retrograde pyelogram, CT urography, renal ultrasound, or MRI urogram: to evaluate the upper tracts
- Urine cytology: to detect abnormal cells in the urine It is essential to note that the risk of underlying cancer in patients with microscopic hematuria is low, ranging from 2.6% to 4% 1, but it is crucial to rule out this possibility through a thorough diagnostic evaluation.
From the Research
Review of Systems (ROS)
- A thorough history and physical examination should be performed to determine potential causes and assess risk factors for malignancy in a 50-year-old male presenting with microscopic hematuria 2
- The ROS should include questions about symptoms such as pain, dysuria, or frequency, as well as a review of the patient's medical history, including any previous urinary tract infections, kidney stones, or other genitourinary conditions 3
Diagnostic Approach
- Laboratory tests, including urinalysis and urine culture, should be performed to rule out intrinsic renal disease and identify any potential underlying causes of the hematuria 2, 4
- Imaging of the urinary tract, such as ultrasound or cross-sectional imaging, may be indicated in certain cases, particularly if there are risk factors for malignancy or if the hematuria is persistent or recurrent 3, 5
- Cystoscopy and urinary cytology may be considered in patients with risk factors for bladder cancer or other genitourinary malignancies 3, 5
Treatment
- There is no specific treatment to resolve or prevent hematuria, and resolution of hematuria usually occurs with appropriate management of the underlying disorder 6
- Treatment should be focused on addressing the underlying cause of the hematuria, whether it be a benign condition such as a urinary tract infection or a more serious condition such as a genitourinary malignancy 2, 4
- Patients with persistent microscopic hematuria should be closely monitored and evaluated to determine the underlying cause and to rule out any potential malignancies 6, 5