From the Guidelines
The initial management for a 40-year-old male non-smoker with hematuria and normal blood work should include a thorough urological evaluation, starting with a repeat urinalysis to confirm the presence of hematuria, followed by cystoscopy and upper tract imaging such as a CT urogram. This approach is supported by the American College of Radiology's Appropriateness Criteria for hematuria, which recommends a thorough history, physical examination, urinalysis, and serologic testing prior to any initial imaging 1. The patient's age and lack of smoking history are important factors to consider, as they may affect the risk of underlying conditions such as bladder cancer or kidney stones.
- The patient should undergo cystoscopy to directly visualize the bladder and urethra, as recommended by the American Urological Association's guidelines for asymptomatic microscopic hematuria 1.
- Upper tract imaging, such as a CT urogram, should be performed to evaluate the kidneys and ureters, as recommended by the American College of Radiology's Appropriateness Criteria for hematuria 1 and the American Urological Association's guidelines for asymptomatic microscopic hematuria 1.
- The patient should be counseled about avoiding anticoagulants temporarily before procedures, as recommended by the American Urological Association's guidelines for asymptomatic microscopic hematuria 1.
- If no cause is identified after initial workup, periodic reassessment with urinalysis every 6-12 months for 2 years is recommended, with further investigation if hematuria persists, as recommended by the American Urological Association's guidelines for asymptomatic microscopic hematuria 1.
From the Research
Initial Management for Hematuria
The initial management for a 40-year-old male non-smoker with hematuria and normal blood work involves a thorough diagnostic evaluation to rule out underlying serious diseases such as bladder cancer, upper urinary tract urothelial cell carcinoma (UUT-UCC), renal cell cancer, or urinary tract stones 2, 3, 4.
Diagnostic Imaging
- CT urography is a recommended initial imaging test for hematuria in patients at high-risk for UCC, due to its high diagnostic accuracy for urothelial cell carcinoma (UCC) and favorable comparison with other imaging techniques 2.
- Ultrasound is vital in the initial assessment of haematuria, particularly in radiation-sensitive patients, low-risk patients, and in young men <40 years 4.
- Computed tomographic urography (CTU) is a sensitive and specific method for the detection of urothelial malignancy, particularly in high-risk patients 4.
- Magnetic resonance urography (MRU) provides better contrast resolution than CTU without exposure to ionising radiation or requiring intravenous (IV) contrast administration, making it more suitable for examination of pediatric and pregnant patients and patients with renal impairment 4.
Evaluation Protocol
The evaluation protocol for hematuria includes:
- Unenhanced scans to evaluate the basic parameters such as the size, shape, position, and outline of the kidneys and calculus disease 3.
- Nephrographic phase to visualize renal parenchymal diseases including masses 3.
- Delayed excretory phases to detect urothelial diseases 3.
- Cystoscopy remains the gold standard in the detection of lower urinary tract (bladder) urothelial tumours 4.