From the Guidelines
For a patient with persistent hematuria and glycosuria, I strongly recommend starting with a renal ultrasound and a bladder ultrasound in conjunction with a risk index, such as the Hematuria Cancer Risk Score, to inform the need for cystoscopy. This approach is supported by the most recent guidelines, including the 2025 AUA/SUFU guideline 1, which emphasizes the importance of a risk-based approach to evaluate hematuria. The use of bladder ultrasound with a risk index can help identify patients who may not require immediate cystoscopy, thus reducing unnecessary procedures and their associated risks.
Recommended Scans
- Renal ultrasound: This is a non-invasive, relatively inexpensive test that does not involve ionizing radiation and can provide reasonable discrimination for cortical lesions, although image quality can be operator-dependent and affected by the patient's body habitus 1.
- Bladder ultrasound: This is crucial for assessing the bladder, especially when optimally distended, to evaluate for bladder cancer or other abnormalities. The sensitivity for identifying bladder cancer with this approach is high, as noted in the validation cohort of the 2025 guideline, where the sensitivity was 97% 1.
- CT urography: This may be considered for further evaluation, especially in intermediate- and high-risk patients, as it provides excellent delineation of the excretory urinary tract and is sensitive for urinary stones and renal cortical lesions. However, it involves ionizing radiation and iodine-based IV contrast, making it more expensive and less suitable for some patients 1.
Additional Considerations
- Urine cytology or urine-based tumor markers (UBTMs) may assist in the decision-making process regarding the utility of cystoscopy but should not replace the recommended imaging studies 1.
- Cystoscopy remains the gold standard for evaluating bladder cancer and should be considered based on the patient's risk category and the results of initial imaging studies 1.
- Blood glucose testing is also essential to evaluate for diabetes, given the presence of glycosuria, which can have significant implications for patient management and outcomes.
By prioritizing these scans and tests, clinicians can ensure a comprehensive evaluation that balances diagnostic accuracy with the risks associated with each test, ultimately aiming to improve patient outcomes by identifying and addressing the underlying causes of hematuria and glycosuria promptly and effectively.
From the Research
Scans for Hematuria and Glycosuria
The following scans are recommended for a patient with persistent hematuria and glycosuria:
- Ultrasound: Conventional ultrasound and color Doppler imaging can be used for initial assessment of renal masses 2
- Computed Tomography (CT): Unenhanced helical computed tomography is the most effective imaging technique for evaluating calculi, and multidetector computed tomography is the most accurate imaging diagnostic test for people with hematuria 3
- CT Urogram: Computerized tomography urogram is recommended when investigating patients with hematuria, especially in cases of macroscopic hematuria or suspected upper tract urothelial cancer 4
- Contrast-Enhanced Ultrasound (CEUS): CEUS improves the sensitivity for detection of small renal masses and can be used to evaluate the characteristics of renal masses 2
Specific Recommendations
- For patients over 40 with microscopic hematuria, a non-contrast computed tomography or ultrasound study should be performed 3
- For patients with gross hematuria, cystoscopy should be added to the imaging studies 3
- For elderly patients, pre- and post-contrast computed tomography scans and cystoscopy should be carried out 3
- Renal and bladder ultrasound can replace computerized tomography urogram in patients with microscopic hematuria, but not in cases of macroscopic hematuria or suspected upper tract urothelial cancer 4