From the Guidelines
The appropriate workup for hematuria in men should begin with a thorough history and physical examination, followed by urinalysis with microscopy to confirm the presence of red blood cells, and all men with confirmed hematuria should undergo cystoscopy and upper tract imaging with CT urography or renal ultrasound. This approach is supported by the American College of Radiology's Appropriateness Criteria for hematuria, which emphasizes the importance of a thorough initial evaluation, including imaging and cystoscopy, to rule out underlying malignancies or other serious conditions 1.
The workup should include laboratory tests such as complete blood count, serum creatinine, and urine culture to rule out infection. Risk factors that warrant more urgent evaluation include age over 35, smoking history, occupational exposures to chemicals or dyes, history of gross hematuria, and irritative voiding symptoms. The American College of Physicians also recommends that clinicians consider urology referral for cystoscopy and imaging in adults with microscopically confirmed hematuria in the absence of a demonstrable benign cause 1.
Key points to consider in the workup of hematuria in men include:
- A thorough history and physical examination to identify potential risk factors and underlying causes
- Urinalysis with microscopy to confirm the presence of red blood cells
- Cystoscopy to directly visualize the bladder and urethra
- Upper tract imaging with CT urography or renal ultrasound to evaluate the kidneys and ureters
- Laboratory tests such as complete blood count, serum creatinine, and urine culture to rule out infection
- Consideration of risk factors that warrant more urgent evaluation, such as age, smoking history, and occupational exposures.
Even microscopic hematuria without symptoms requires thorough evaluation, as approximately 5% of these cases may reveal significant urological pathology. If initial evaluation is negative but hematuria persists, follow-up evaluation should be considered within 6-12 months, as recommended by the American Urological Association 1.
From the Research
Workup of Hematuria in Men
The workup of hematuria (blood in the urine) in men involves a series of tests and evaluations to determine the underlying cause of the condition. According to 2, hematuria can be a sign of serious underlying diseases, including urinary cancers, and therefore requires aggressive evaluation.
Initial Evaluation
The initial evaluation of hematuria in men includes:
- History and physical examination
- Microscopic urinalysis to confirm the presence of blood in the urine
- Further testing based on the results of the initial evaluation, such as imaging studies and cystoscopy
Imaging Studies
Imaging studies, such as renal bladder ultrasound (RBUS), can be used to evaluate the urinary tract and detect any abnormalities. According to 3, the use of RBUS with the Hematuria Cancer Risk Score (HCRS) can inform cystoscopy use in patients with hematuria and spare selected patients from an invasive procedure.
Cystoscopy
Cystoscopy is a procedure that allows for visual examination of the bladder and urethra. According to 4, cystoscopy is underutilized in the evaluation of hematuria, with only 9% of patients undergoing the procedure. However, cystoscopy is an important tool for detecting bladder cancer and other urinary tract abnormalities.
Referral to a Urologist
Referral to a urologist is an important part of the workup of hematuria in men. According to 4, male gender, ethnicity, and gross hematuria are associated with a higher rate of urological referral. However, many patients with hematuria are not referred to a urologist, which can delay diagnosis and treatment of underlying conditions.
Key Findings
Key findings from the studies include:
- Hematuria can be a sign of serious underlying diseases, including urinary cancers 2
- The degree of hematuria is unrelated to the seriousness of its cause 2, 5
- Imaging studies, such as RBUS, can be used to evaluate the urinary tract and detect abnormalities 3
- Cystoscopy is an important tool for detecting bladder cancer and other urinary tract abnormalities, but is underutilized in the evaluation of hematuria 4
- Referral to a urologist is an important part of the workup of hematuria in men, particularly for those with gross hematuria or other risk factors 4