What is the diagnostic workup for a male patient presenting with hematuria (blood in urine)?

Diagnostic Workup for Male Patients with Hematuria

Cystoscopy and CT urography are the cornerstone diagnostic tests for evaluating hematuria in male patients, with cystoscopy demonstrating sensitivity of 87-100% for detecting bladder cancer. 1

Initial Assessment

• Confirm hematuria: ≥3 red blood cells per high-power field constitutes true hematuria requiring evaluation 2
• Risk stratification factors that increase likelihood of malignancy:
  • Age >60 years
  • Smoking history
  • Gross hematuria (>10% risk of malignancy)
  • Exposure to industrial chemicals
  • History of pelvic radiation
  • Family history of renal cancer 2

Diagnostic Algorithm

Step 1: Laboratory Testing

• Complete urinalysis to confirm hematuria and assess for:
  • Proteinuria (suggests glomerular disease)
  • Pyuria (suggests infection)
  • RBC morphology (dysmorphic RBCs suggest glomerular source)
• Serum creatinine and BUN to assess renal function
• Urine culture if infection suspected

Step 2: Imaging

• CT urography is the first-line imaging modality with 92% sensitivity and 93% specificity 2

  • Should include unenhanced images, contrast-enhanced nephrographic phase, and excretory phase
  • Evaluates for upper tract tumors, stones, and other abnormalities

• Alternative imaging options:

  • MR urography: For patients with contrast allergy or renal insufficiency
  • Renal ultrasound: Lower sensitivity (50%) but may be used as initial test in younger patients 2

Step 3: Cystoscopic Evaluation

• White light cystoscopy is mandatory for all adult males with hematuria 1, 2

  • Sensitivity ranges from 87% to 100% for detecting bladder cancer 1
  • Specificity ranges from 64% to 100% 1
  • Negative predictive value is 98-100% 1

• Note: Blue light cystoscopy should NOT be used in the initial evaluation of asymptomatic microhematuria (Grade C recommendation) 1

Follow-up Recommendations

• For patients with negative initial evaluation:

  • If persistent asymptomatic microhematuria (AMH), yearly urinalyses should be conducted (Grade C recommendation) 1
  • After two consecutive negative annual urinalyses, no further urinalyses for AMH evaluation are necessary 1
  • For persistent/recurrent AMH after negative workup, repeat evaluation within 3-5 years should be considered 1

• For patients with ongoing risk factors:

  • More vigilant follow-up is warranted as microhematuria may precede bladder cancer diagnosis by many years 1

Important Clinical Considerations

• Hematuria is often intermittent, even when caused by serious disease 3, 4
• The degree of hematuria does not correlate with the seriousness of the underlying cause 3
• Anticoagulation may exacerbate bleeding but rarely causes hematuria without underlying pathology 2
• Patients on anticoagulants still require complete hematuria evaluation 2

Potential Complications of Cystoscopy

• Pain and discomfort
• Hematuria
• Dysuria
• Urinary tract infection 1

The diagnostic accuracy of cystoscopy exceeds that of any other imaging test for detecting bladder cancer in patients with hematuria, making it an essential component of the evaluation 1.