What is the evaluation and treatment approach for gross hematuria?

Evaluation and Management of Gross Hematuria

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

Initial Evaluation

History and Risk Assessment

• Assess for risk factors for urologic malignancy:
  • Age >60 years
  • Male gender
  • Smoking history
  • Occupational exposure to chemicals or dyes
  • Family history of renal cell carcinoma 2
• Determine if hematuria is associated with:
  • Pain (suggests stones or infection)
  • Painless (higher concern for malignancy)
  • Recent trauma, vigorous exercise, or procedures 2
• Ask about anticoagulant/antiplatelet medication use (does NOT eliminate need for evaluation) 1, 2

Initial Testing

• Confirm presence of hematuria with microscopic urinalysis
• Urinalysis with microscopic examination to assess for:
  • RBC morphology (dysmorphic RBCs suggest glomerular source)
  • Presence of proteinuria
  • Evidence of infection (pyuria, bacteria) 2
• Basic metabolic panel to assess renal function
• Urine culture if infection suspected

Diagnostic Workup

Imaging

• CT urography is the first-line imaging modality, including:
  • Unenhanced images
  • Contrast-enhanced nephrographic phase
  • Excretory phase 2
• Alternative imaging options for patients with contraindications:
  • MR urography (for contrast allergy or renal insufficiency)
  • Renal ultrasound (less sensitive) 2

Cystoscopy

• Required for all adult patients with gross hematuria
• Flexible cystoscopy preferred (equivalent diagnostic accuracy to rigid with less discomfort) 2
• Evaluates for bladder tumors, stones, inflammatory lesions, and urethral strictures

Additional Testing

• Do NOT obtain urinary cytology or other urine-based molecular markers for bladder cancer detection in the initial evaluation 1, 2
• Consider nephrology referral if significant proteinuria, dysmorphic RBCs, RBC casts, or elevated serum creatinine 2

Common Causes of Gross Hematuria

Malignant Causes (>10% risk)

• Bladder cancer (higher risk in older males, smokers)
• Renal cell carcinoma
• Upper tract urothelial carcinoma
• Prostate cancer

Benign Causes

• Urinary tract infection (most common cause of dysuria with hematuria) 2
• Urinary calculi (often with flank pain)
• Benign prostatic hyperplasia (common in older males) 2
• Trauma or vigorous exercise (transient)
• Medication-related (anticoagulants/antiplatelets increase bleeding but are NOT the cause) 3

Follow-up and Surveillance

• If initial evaluation is negative:
  • Repeat urinalysis, urine cytology, and blood pressure checks at 6,12,24, and 36 months 2
  • Immediate re-evaluation if:
    • Recurrent gross hematuria
    • Abnormal urinary cytology
    • New irritative voiding symptoms in absence of infection 2

Clinical Pitfalls

• Anticoagulant or antiplatelet therapy does NOT eliminate the need for complete hematuria evaluation 1, 3
• Studies show inadequate referral rates for gross hematuria (only 69-77% of patients are referred to urology) 4
• Even with excessive anticoagulation, underlying tumors may be present in up to 18% of patients 3
• Delaying evaluation can lead to delayed diagnosis of potentially curable malignancies

Remember that gross hematuria represents a significant warning sign that requires prompt and thorough evaluation to rule out serious underlying conditions, particularly malignancy.