What is the evaluation and management approach for a patient with hematuria (blood in the urine)?

Evaluation and Management of Hematuria

All patients with gross hematuria should be referred for urologic evaluation, even if self-limited, due to the high risk of underlying urinary tract cancer (>10%). 1

Initial Assessment

Classification of Hematuria

• Gross hematuria: Visible blood in urine

  • Higher risk for malignancy (>10% risk) 2
  • Painless gross hematuria has stronger association with cancer 1
  • Symptomatic gross hematuria with flank pain suggests urinary stone disease 1

• Microscopic hematuria: Blood detected on urinalysis

  • Defined as ≥3 erythrocytes per high-powered field on microscopic examination 1
  • Lower but still significant risk of malignancy (0.5-5%) 1

Key History Elements

• History of gross hematuria episodes (even in patients with microscopic hematuria)
• Smoking history (increases risk of urologic malignancy)
• Age (risk increases with age)
• Medication use, particularly anticoagulants/antiplatelets
• Associated symptoms (dysuria, frequency, flank pain)

Diagnostic Algorithm

1. For dipstick-positive hematuria:

   • Confirm with microscopic urinalysis showing ≥3 RBCs/HPF before further evaluation 1
   • Do not use screening urinalysis for cancer detection in asymptomatic adults 1

2. For gross hematuria:

   • Urgent urologic referral for cystoscopy and imaging regardless of whether it resolves 1
   • Do not delay evaluation even if patient is on antiplatelet or anticoagulant therapy 1

3. For confirmed microscopic hematuria:

   • Evaluate for benign causes:
     • Urinary tract infection
     • Benign prostatic hyperplasia
     • Urinary calculi
     • Recent vigorous exercise
     • Menstruation
   • If no benign cause identified:
     • Refer for urologic evaluation (cystoscopy and imaging) 1, 2
     • Laboratory tests to evaluate for intrinsic renal disease 2

Important Considerations

• Anticoagulation therapy: Pursue evaluation of hematuria even in patients on anticoagulant/antiplatelet therapy, as these medications may unmask significant urologic pathology 1, 3

• Avoid unnecessary testing: Do not obtain urinary cytology or other urine-based molecular markers for bladder cancer detection in the initial evaluation 1

• Risk stratification: Consider patient risk factors when determining urgency of referral:

  • Higher risk: Male gender, age >35 years, smoking history, gross hematuria 1, 2
  • Lower risk: Younger patients, microscopic hematuria with identified benign cause

Common Pitfalls to Avoid

1. Failure to refer patients with gross hematuria: Studies show only 69-77% of patients with gross hematuria are referred to urology despite guidelines recommending 100% referral 4

2. Undervaluing microscopic hematuria: Only 36% of patients with microscopic hematuria are referred to urologists 5, 4

3. Incomplete evaluation: Many patients do not receive recommended imaging and cystoscopy, with studies showing only 35.6% receive imaging and 9% receive cystoscopy 5

4. Attributing hematuria to anticoagulation without proper evaluation: Hematuria in patients on anticoagulants still requires complete evaluation 1, 3

5. Overreliance on dipstick testing without microscopic confirmation: Dipstick positivity should be confirmed with microscopic examination before initiating extensive workup 1

The systematic evaluation of hematuria is critical as it may be the first sign of serious urologic disease, including malignancy. Following evidence-based guidelines for referral and evaluation can significantly reduce delays in diagnosis and improve outcomes.