From the Guidelines
The workup for hematuria should begin with a thorough history, physical examination, and urinalysis to confirm the presence of blood in the urine, followed by imaging studies such as renal ultrasound or CT urography, and cystoscopy for adults over 35 with microscopic hematuria and all patients with gross hematuria, as recommended by the most recent guidelines 1. The initial evaluation should also include laboratory tests such as complete blood count, comprehensive metabolic panel, and urine culture to assess for infection. Key points to consider in the workup include:
- The definition of microscopic hematuria as three or more red blood cells per high-power field on microscopic evaluation of urinary sediment from two of three properly collected urinalysis specimens 1.
- The importance of cystoscopy in detecting bladder cancer, with sensitivities ranging from 87% to 100% and specificity ranging from 64% to 100% 1.
- The need for upper urinary tract imaging in all adults with asymptomatic microscopic hematuria in the absence of known benign causation 1.
- The consideration of risk factors such as age, smoking history, occupational exposures, and whether the hematuria is gross or microscopic in determining the urgency and extent of the workup 1.
- The potential for interstitial cystitis/bladder pain syndrome to mimic other conditions and the importance of a proper hematuria workup in patients with un-evaluated hematuria or tobacco exposure 1. Given the potential for hematuria to signal serious conditions, prompt evaluation is crucial, and the workup should be tailored to the individual patient's risk factors and presentation.
From the Research
Workup for Hematuria
The workup for hematuria, which is the presence of blood in the urine, involves a thorough evaluation to determine the underlying cause. This includes:
- A thorough history and physical examination to determine potential causes and assess risk factors for malignancy 2
- Laboratory tests to rule out intrinsic renal disease 2
- Imaging of the urinary tract, such as intravenous pyelography or sonography, which is usually the first procedure performed 3
- Cystoscopy, which is indicated in the face of active bleeding 3
- Referral to nephrology and urology subspecialists if no benign cause is found 2
Classification of Hematuria
Hematuria is classified as either gross or microscopic, with different approaches to evaluation and management:
- Gross hematuria has a greater than 10% risk of malignancy and warrants prompt urologic referral 2
- Microscopic hematuria most commonly has benign causes, such as urinary tract infection, benign prostatic hyperplasia, and urinary calculi, but may require further evaluation to rule out malignancy 2
Diagnostic Approach
The diagnostic approach to hematuria is guided by the patient's age, sex, medical history, and physical examination:
- A focused history and physical, including laboratory studies and diagnostic imaging, drives the workup 4
- The cause of hematuria often originates in the genitourinary tract, but may also be due to nongenitourinary tract causes, which may require emergent management 4
- Patients with hematuria, especially the elderly, are at risk for urologic malignancy, and prompt evaluation and follow-up are essential 4