What are the guidelines for gross hematuria (visible blood in urine)?

From the Guidelines

All adults presenting with gross hematuria should undergo urgent urologic evaluation due to the relatively high pretest probability of cancer or other clinically significant underlying conditions. The evaluation of gross hematuria is crucial as it can be a marker of occult urinary tract cancer, and the risk of underlying cancer varies greatly 1. Gross hematuria can have a dramatic presentation, and its symptoms can range from painless to symptomatic with associated flank pain or renal colic, which is often associated with urinary stone disease 1.

Key Considerations in Evaluation

• A complete urologic workup is necessary, including a detailed history, physical examination, urinalysis, and imaging studies.
• Initial assessment should focus on determining if the bleeding is from the upper or lower urinary tract.
• Patients with risk factors such as age over 40, smoking history, occupational exposures, or a history of urologic disorders should be referred to a urologist 1.
• The diagnostic evaluation typically includes cystoscopy to directly visualize the bladder and urethra, along with CT urography or renal ultrasound to assess the kidneys and ureters.
• Urine cytology should be performed to screen for malignancy.

Urgent Situations

Gross hematuria is considered a urologic emergency if accompanied by clots causing urinary retention, significant blood loss leading to hemodynamic instability, or severe pain 1. In such cases, immediate medical attention is required to prevent complications and improve outcomes. The approach to managing gross hematuria should prioritize ruling out serious conditions such as urologic malignancies, kidney stones, infections, or glomerular diseases, as delayed diagnosis could lead to worse outcomes 1.

From the Research

Guidelines for Gross Hematuria

The guidelines for gross hematuria, which is defined as the visible presence of blood in the urine, are as follows:

• Gross hematuria is a significant finding that may indicate serious underlying urologic disease, with a risk of malignancy greater than 10% 2
• Patients with gross hematuria should undergo a thorough history and physical examination to determine potential causes and assess risk factors for malignancy 2
• Prompt urologic referral is recommended for patients with gross hematuria 2
• Evaluation of gross hematuria may include:
  • Imaging studies such as plain X-rays, ultrasound, intravenous urography, computed tomography (CT), magnetic resonance imaging, retrograde ureterography and pyelography (RGP) 3
  • Cystoscopy and ureteroscopy 3
  • Urine cytologic studies and urine cultures 4
• CT urography is a useful diagnostic tool for evaluating gross hematuria, and can be used alone for this purpose 3

Referral Patterns for Gross Hematuria

Referral patterns for gross hematuria vary among primary care physicians, with:

• Only 77% of primary care physicians in Miami and 69% in Dallas reporting that they refer patients with gross hematuria to an urologist 5
• Many primary care physicians do not automatically refer patients with microscopic hematuria to urology, and not all patients with gross hematuria are referred 5

Importance of Evaluation

Evaluation of gross hematuria is crucial, as it may indicate a significant underlying condition, and delayed or deferred investigation can lead to a disservice to the patient 4