What are the next steps for a patient with hematuria?

Management of Hematuria

For a patient with hematuria (blood value "HI" on urinalysis), urgent urologic referral for cystoscopy and imaging is required to rule out urinary tract cancer, which occurs in >10% of patients with gross hematuria. 1

Initial Assessment

1. Determine type of hematuria:

   • The urinalysis shows "HI" blood value, which indicates significant hematuria
   • Confirm if this is gross hematuria (visible blood) or microscopic hematuria
   • Ask specifically about any history of gross hematuria, even if currently microscopic 1

2. Assess for benign causes:

   • Recent vigorous exercise
   • Sexual activity
   • Menstruation (in women)
   • Trauma
   • Active urinary tract infection
   • Kidney stones

3. Risk factor assessment:

   • Age (older patients have higher risk of malignancy)
   • Smoking history
   • Occupational exposures to chemicals or dyes
   • History of pelvic irradiation
   • Cyclophosphamide use
   • Chronic analgesic use

Diagnostic Algorithm

For Gross Hematuria:

• Immediate urologic referral is required regardless of whether it was self-limited 1
• The risk of urinary tract cancer exceeds 10% with gross hematuria 1, 2
• Do not delay evaluation even if patient is on antiplatelet or anticoagulant therapy 1

For Microscopic Hematuria:

1. Confirm with microscopic urinalysis (≥3 RBCs per high-power field) 1

2. Evaluate for glomerular vs. non-glomerular source:

   • Check for dysmorphic RBCs, RBC casts, or significant proteinuria 1
   • Measure serum creatinine to assess renal function 1

3. If glomerular source suspected:

   • Nephrology referral is appropriate 1
   • Monitor for development of hypertension, renal insufficiency, or proteinuria 1

4. If non-glomerular source:

   • Urologic referral for cystoscopy and imaging in the absence of benign cause 1
   • Do not obtain urinary cytology or other urine-based molecular markers in initial evaluation 1

Imaging and Further Testing

• Upper urinary tract imaging (CT urography preferred)
• Cystoscopic examination of the bladder
• Laboratory analysis including comprehensive urinalysis and serum creatinine
• For patients with risk factors for transitional cell carcinoma, voided urinary cytology may be useful 1

Follow-up

• If a benign cause is identified and treated (e.g., UTI), repeat urinalysis 6 weeks after treatment 1
• If hematuria resolves, no additional evaluation is necessary
• Patients with isolated hematuria (negative urologic evaluation and no evidence of glomerular bleeding) should be monitored for development of hypertension, renal insufficiency, or proteinuria 1

Common Pitfalls to Avoid

1. Delaying evaluation due to anticoagulant therapy - Hematuria should be evaluated even in patients on antiplatelet or anticoagulant therapy 1

2. Attributing hematuria to UTI without follow-up - Always confirm resolution of hematuria after treating UTI; persistent hematuria requires complete evaluation 1

3. Incomplete evaluation - Both upper and lower urinary tracts must be evaluated in patients with persistent hematuria

4. Overlooking glomerular causes - Check for dysmorphic RBCs, proteinuria, and renal function to identify potential glomerular disease 1

5. Relying on urine cytology alone - Cystoscopy is required if cytology shows malignant or atypical/suspicious cells 1