From the Guidelines
The initial workup for a patient presenting with gross hematuria should include a thorough history, physical examination, laboratory tests, and imaging studies, with a focus on identifying potential underlying malignancies, as the risk of cancer is high, up to 30-40% 1. The workup should begin with a complete history, focusing on the timing and characteristics of hematuria, associated symptoms, medication use (especially anticoagulants), and risk factors for urologic malignancies.
- Key aspects of the history include:
- Age and sex
- History of gross hematuria
- Irritative urinary symptoms
- Overall health status
- Risk factors for malignancy, such as smoking, occupational exposure to chemicals, and family history of urologic malignancies Physical examination should assess vital signs, abdominal tenderness, and include a genitourinary examination. Laboratory tests should include:
- Urinalysis with microscopy to confirm hematuria and assess for infection
- Complete blood count to evaluate for anemia
- Comprehensive metabolic panel to assess renal function
- Urine culture if infection is suspected
- Coagulation studies if the patient is on anticoagulants or has bleeding disorders Imaging typically starts with renal ultrasound to identify stones, masses, or hydronephrosis, followed by CT urography for more detailed evaluation of the entire urinary tract, as recommended by the American College of Radiology 1. Cystoscopy is often necessary, especially in patients over 35 years or with risk factors for bladder cancer, to directly visualize the bladder and urethra, as suggested by the American Urological Association 1. This comprehensive approach is essential because gross hematuria can indicate serious underlying conditions, including malignancy, urolithiasis, infection, or glomerular disease, requiring prompt and thorough evaluation, and the most recent guidelines from 2025 emphasize the importance of a thorough initial evaluation 1.
From the Research
Initial Workup for Gross Hematuria
The initial workup for a patient presenting with gross hematuria involves a thorough history and physical to determine potential causes and assess risk factors for malignancy 2.
Risk Assessment and Referral
Given that the risk of malignancy with gross hematuria is greater than 10%, prompt urologic referral is recommended 2.
Diagnostic Imaging
CT urography is defined as CT examination of the kidneys, ureters, and bladder with at least one series of images acquired during the excretory phase after intravenous contrast administration, and it is recommended as the initial imaging test for hematuria in patients at high-risk for urothelial cell carcinoma (UCC) 3.
Laboratory Tests and Other Evaluations
The workup may also include laboratory tests such as urinalysis, urine culture, and coagulation studies, as well as other evaluations like intravenous pyelography, cystoscopy, renal ultrasonography, and renal arteriography 4.
National Practice Recommendations
National practice recommendations suggest referral to urology for all people with gross hematuria or high-grade hematuria (>50 red blood cells per high-power field [RBCs/HPF]) on a single urinalysis (UA), and voided urinary cytology should be eliminated from asymptomatic hematuria screening protocol 5.
Specific Conditions
In some cases, gross hematuria may be associated with specific conditions such as emphysematous cystitis, which can be diagnosed with an abdominal CT scan and cystoscopy, and treated conservatively with broad spectrum antibiotics 6.
- Key steps in the initial workup for gross hematuria include:
- Thorough history and physical
- Risk assessment for malignancy
- Prompt urologic referral
- Diagnostic imaging with CT urography
- Laboratory tests and other evaluations as needed
- The workup and management of gross hematuria should be guided by national practice recommendations and tailored to the individual patient's needs and risk factors 2, 3, 5.