What is the appropriate evaluation and management for a patient with hematuria?

Evaluation and Management of Hematuria

Patients with hematuria require a risk-stratified evaluation approach, with all patients with gross hematuria and high-risk patients with microscopic hematuria requiring complete urologic evaluation including cystoscopy and upper tract imaging to rule out urologic malignancy. 1

Definition and Classification

• Microscopic hematuria: ≥3 red blood cells per high-power field (HPF) on a properly collected urinalysis specimen 1
• Gross hematuria: Visible blood in urine, which carries a higher risk of underlying malignancy (>10% and >25% in some referral series) 1

Risk Stratification for Microscopic Hematuria

The 2020 AUA/SUFU guidelines recommend categorizing patients with microscopic hematuria into risk groups 1:

High-Risk Factors:

• Age ≥60 years
• Male sex
• History of smoking
• Occupational exposure to chemicals or dyes
• History of gross hematuria
• History of urologic disorder or disease
• History of irritative voiding symptoms
• History of pelvic irradiation
• Family history of urologic malignancy

Risk Categories:

1. Low-risk: Women <50 years with no other risk factors
2. Intermediate-risk: Women ≥50 years or men <60 years with no other risk factors
3. High-risk: Any patient with high-risk factors listed above

Initial Evaluation

1. Detailed history: Focus on risk factors for urologic malignancy, timing of hematuria, associated symptoms (pain, dysuria, frequency) 1, 2

2. Physical examination: Abdominal masses, costovertebral angle tenderness, genital examination 2

3. Laboratory testing:

   • Urinalysis with microscopic examination
   • Urine culture to rule out infection
   • Serum creatinine and BUN to assess renal function
   • Complete blood count 2

4. Assessment for non-urologic causes:

   • Menstruation, vaginal bleeding, or trauma in women
   • Vigorous exercise
   • Recent urologic procedures
   • Medications (anticoagulants may exacerbate but rarely cause hematuria) 2

Diagnostic Algorithm

For Gross Hematuria:

• All patients require urgent and complete urologic evaluation regardless of risk factors 1
• Complete evaluation includes cystoscopy and upper tract imaging 1

For Microscopic Hematuria:

1. Rule out benign causes:

   • Urinary tract infection
   • Menstruation
   • Vigorous exercise
   • Recent urologic procedures 1

2. Assess for signs of glomerular disease:

   • Significant proteinuria (>1000 mg/24 hours)
   • Red cell casts
   • Dysmorphic RBCs
   • Renal insufficiency 1, 2

   If present → Nephrology referral (but still perform risk-based urologic evaluation) 1

3. Risk-based evaluation:

   • Low-risk: Renal ultrasound 1
   • Intermediate-risk: Cystoscopy and renal ultrasound 1
   • High-risk: Cystoscopy and CT urography (or MR urography if contrast allergy/renal insufficiency) 1, 2

Imaging Recommendations

• CT Urography: Primary imaging modality for high-risk patients (92% sensitivity, 93% specificity) 2
• MR Urography: Alternative for patients with contrast allergy or renal insufficiency 2
• Renal Ultrasound: Appropriate for low-risk patients or as initial screening (50% sensitivity, 95% specificity) 2

Cystoscopy

• Mandatory for all adult patients with gross hematuria and intermediate/high-risk patients with microscopic hematuria 1, 2
• Sensitivity ranges from 87% to 100% for detecting bladder cancer 2

Follow-up Recommendations

1. Negative initial evaluation:

   • Repeat urinalysis at 6,12,24, and 36 months 2
   • Immediate re-evaluation if recurrent gross hematuria, abnormal urinary cytology, or new irritative voiding symptoms occur 2

2. Persistent asymptomatic microscopic hematuria:

   • Annual urinalysis 2
   • Consider repeat evaluation within 3-5 years 2

3. Low-risk patients who initially declined evaluation:

   • If hematuria persists on repeat testing, reclassify as intermediate/high-risk and perform complete evaluation 1

Common Pitfalls to Avoid

1. Ignoring microscopic hematuria: Only 36% of primary care physicians refer patients with microscopic hematuria to urologists 3

2. Assuming anticoagulation is the cause: Anticoagulant therapy may exacerbate bleeding but rarely causes it without underlying pathology and does not eliminate the need for complete evaluation 2

3. Inadequate follow-up: Patients with negative initial evaluation still require surveillance as delayed diagnosis of malignancy can occur 2

4. Missing glomerular causes: The presence of significant proteinuria, red cell casts, or dysmorphic RBCs should prompt nephrology evaluation 1

5. Incomplete evaluation in high-risk patients: High-risk patients require both cystoscopy and CT urography for complete assessment 1