From the Guidelines
Hematuria evaluation should begin with a thorough history, physical examination, and urinalysis, followed by cystoscopy for all patients with gross hematuria and those over 35 years with microscopic hematuria after excluding benign causes, as recommended by the most recent guidelines 1.
Diagnostic Approach
The diagnostic approach for hematuria involves:
- A thorough history and physical examination to determine the source of the blood
- Urinalysis to confirm the presence of blood in the urine
- Imaging studies such as CT urography or renal ultrasound to assess the upper urinary tract
- Cystoscopy to visualize the bladder lining and detect any lesions or abnormalities
Cystoscopy
Cystoscopy is a crucial diagnostic tool for detecting bladder cancer and other abnormalities in patients with hematuria. It is indicated for all patients with gross hematuria and those over 35 years with microscopic hematuria after excluding benign causes 1. The procedure involves inserting a flexible or rigid scope through the urethra to visualize the bladder lining and is typically done under local anesthesia in an outpatient setting.
Management
The management of hematuria depends on the underlying cause and may involve:
- Further evaluation and testing to determine the source of the blood
- Treatment of any underlying conditions, such as infections or stones
- Surveillance and monitoring for patients with risk factors or persistent hematuria
- Referral to a specialist, such as a urologist, for further evaluation and treatment
Risk Factors
Patients with risk factors such as smoking history, chemical exposure, or prior pelvic radiation may require more vigilant surveillance and monitoring 2. These patients are at higher risk of developing bladder cancer and other serious conditions, and prompt diagnosis and treatment are essential to improve outcomes.
Follow-up
Patients with negative findings but persistent hematuria should have repeat urinalysis at 6, 12, and 24 months to monitor for any changes or developments 3. This comprehensive approach is necessary because hematuria can signal serious conditions, including malignancy, stones, or glomerular disease, that require prompt diagnosis and management.
From the Research
Diagnostic Approach for Hematuria
- Hematuria can be either grossly visible (macrohematuria) or only detectable under a microscope (microhematuria) 4
- The basic diagnostic evaluation consists of a thorough history and physical examination, measurement of inflammatory parameters and renal function tests, and ultrasonography of the kidneys and bladder 4
- Microscopic hematuria is said to be present when urine microscopy reveals three or more erythrocytes per high-power field 4
Management Approach for Asymptomatic Microhematuria
- A risk-adapted diagnostic strategy for the evaluation of asymptomatic microhematuria (aMH) is presented, with patients with non-glomerular aMH who have risk factors such as smoking, advanced age, and male sex undergoing augmented, risk-adapted diagnostic evaluation with urethrocystoscopy, urine cytology, and, when indicated, CT urography 4
- Patients with isolated glomerular hematuria are at elevated risk for renal disease and should undergo follow-up checks at six-month intervals 4
- The American Urological Association has published an updated guideline for the management of asymptomatic microscopic hematuria, which recommends evaluation of the upper urinary tract with multiphasic computed tomography urography and the lower urinary tract with cystoscopy 5
Role of Cystoscopy in Hematuria
- Cystoscopy is recommended for the evaluation of the lower urinary tract in patients with asymptomatic microscopic hematuria, particularly those with risk factors for malignancy 5
- Cystoscopy can help identify urethral stricture disease, benign prostatic hyperplasia, and bladder masses 5
- Urethrocystoscopy is also recommended as part of the augmented, risk-adapted diagnostic evaluation for patients with non-glomerular aMH who have risk factors such as smoking, advanced age, and male sex 4
Other Diagnostic Tests
- Ultrasonography of the kidneys and bladder is part of the basic diagnostic evaluation for hematuria 4
- CT urography is recommended for the evaluation of the upper urinary tract in patients with asymptomatic microscopic hematuria, particularly those with risk factors for malignancy 5
- Urine cytology is no longer recommended as part of the routine evaluation of asymptomatic microscopic hematuria, unless there are risk factors for malignancy 5