From the Guidelines
Diagnosing hematuria in adults requires a systematic approach beginning with confirmation of true hematuria through microscopic urinalysis that demonstrates 3 or more erythrocytes per high-powered field, as recommended by the American College of Physicians 1. The diagnostic approach for hematuria in adults involves several key steps:
- Confirmation of hematuria through urinalysis, with a focus on microscopic examination to rule out false positives from dipstick testing
- Detailed medical history to identify risk factors such as smoking, chemical exposures, and family history of kidney disease or urologic malignancies
- Physical examination to assess for signs of underlying conditions, such as costovertebral angle tenderness or abdominal masses
- Laboratory testing, including complete blood count, comprehensive metabolic panel, and urine culture to rule out infection
- Imaging studies, such as renal ultrasound or CT urography, for persistent hematuria without infection
- Cystoscopy for adults over 35 with risk factors for bladder cancer, particularly those with gross hematuria, as recommended by the American College of Physicians 1 Key considerations in the diagnostic approach include:
- Referral for further urologic evaluation is recommended for all adults with gross hematuria, even if self-limited, and for those with microscopically confirmed hematuria in the absence of a demonstrable benign cause 1
- Evaluation of hematuria should be pursued even in patients receiving antiplatelet or anticoagulant therapy, as these medications do not negate the need for further investigation 1
- Urine cytology or other urine-based molecular markers for bladder cancer detection are not recommended in the initial evaluation of hematuria, according to the American College of Physicians 1
From the Research
Diagnostic Approaches for Hematuria in Adults
The diagnostic approaches for hematuria in adults involve a combination of medical history, physical examination, laboratory studies, and imaging tests. The following are some of the diagnostic approaches used:
- Comprehensive history and focused physical examination to investigate the cause of hematuria 2
- Laboratory studies, such as urinalysis, to confirm the presence of blood in the urine
- Image-based assessment of the upper urinary tract, including:
- Cystoscopic evaluation of the lower urinary system to detect urothelial diseases and other abnormalities 2, 5, 4
- CT urography, which includes an unenhanced scan, the nephrographic phase, and the excretory phase, to evaluate the kidneys, ureters, and bladder 3, 6
Imaging Tests for Hematuria
Imaging tests play a crucial role in the diagnosis of hematuria. The following are some of the imaging tests used:
- CT urography, which is a rapidly evolving technique that can detect urothelial cell carcinoma (UCC) and other abnormalities with high diagnostic accuracy 6
- Ultrasonography, which can detect renal parenchymal diseases and other abnormalities
- Intravenous urography, which can detect urothelial diseases and other abnormalities
- Retrograde ureteropyelography, which can detect urothelial diseases and other abnormalities
Evaluation of Asymptomatic Microscopic Hematuria
Asymptomatic microscopic hematuria is occasionally detected on routine urinalysis. The following are some of the steps involved in the evaluation of asymptomatic microscopic hematuria:
- Thorough medical history, including a review of current medications
- Focused physical examination
- Laboratory and imaging studies, such as intravenous pyelography, renal ultrasonography, or retrograde pyelography, to determine the degree and location of the associated disease process 5
- Cystourethroscopy to complete the evaluation of the lower urinary tract 5