From the Guidelines
The next best diagnostic test for a patient presenting with painless gross hematuria and a normal CT urogram is cystoscopy. This procedure involves inserting a thin, flexible tube with a camera (cystoscope) through the urethra to directly visualize the bladder lining and urethra. Cystoscopy should be performed promptly, ideally within 2-4 weeks of the initial presentation, as it can detect bladder tumors, stones, or inflammatory lesions that may not be visible on imaging studies 1. The procedure is typically done under local anesthesia in an outpatient setting and takes about 15-30 minutes to complete.
Importance of Cystoscopy
Cystoscopy is particularly important because bladder cancer often presents with painless hematuria, and early-stage tumors may be missed on CT urogram, especially if they are small or flat lesions like carcinoma in situ 1. According to a systematic review from the European Association of Urology guidelines office, cystoscopy has been the cornerstone diagnostic tool to inspect the entire bladder for malignancy or other abnormalities in case of hematuria 1.
Additional Workup
If the cystoscopy is normal and no cause for hematuria is identified, additional workup may include urine cytology to detect malignant cells, or referral to nephrology to evaluate for glomerular causes of bleeding 1. Patients should be informed that while cystoscopy is generally safe, they may experience mild discomfort, urinary frequency, or burning with urination for a day or two after the procedure.
Key Points
- Cystoscopy is the gold standard for evaluating bladder cancer
- It should be performed promptly, ideally within 2-4 weeks of the initial presentation
- Additional workup may include urine cytology or referral to nephrology if cystoscopy is normal
- Patients should be informed of the potential risks and benefits of cystoscopy 1.
From the Research
Diagnostic Approach for Painless Gross Hematuria
The patient presents with painless gross hematuria, which can be a symptom of serious diseases such as bladder cancer, upper urinary tract urothelial cell carcinoma (UUT-UCC), renal cell cancer, or urinary tract stones. Given the normal CT urogram, the next step in diagnosis should focus on evaluating the bladder and urethra.
Considerations for Next Diagnostic Test
- The CT urogram has already been performed and showed no stones, masses, or cysts, suggesting that the cause of hematuria may be related to the bladder or urethra 2.
- Studies have shown that CT urography is an accurate test for diagnosing bladder cancer, but its sensitivity is not sufficient to replace cystoscopy 3.
- Cystoscopy is considered the gold standard for evaluating the bladder and urethra, especially in patients with painless gross hematuria 4, 5.
- Repeat urinalysis or 24-hour urine protein measurement may not provide additional information to guide the diagnosis of the cause of hematuria.
Recommended Next Diagnostic Test
Based on the evidence, the most appropriate next diagnostic test to perform is:
- A. Cystoscopy: This procedure allows for direct visualization of the bladder and urethra, which is essential for diagnosing bladder cancer or other abnormalities that may be causing the hematuria 6, 4, 5.
The use of cystoscopy as a diagnostic tool is supported by studies that highlight its importance in evaluating patients with hematuria, especially when other imaging tests like CT urography are normal or inconclusive 2, 3.