What is the appropriate workup for hematuria (blood in urine) with urethral discharge?

From the Guidelines

The appropriate workup for hematuria with urethral discharge should begin with a thorough history, physical examination, urinalysis, and serologic testing, followed by specific diagnostic tests such as nucleic acid amplification tests (NAATs) for sexually transmitted infections (STIs) and urine culture to check for infection. According to the American College of Radiology Appropriateness Criteria for hematuria 1, all patients diagnosed with microhematuria should undergo a thorough history, physical examination, urinalysis, and serologic testing prior to any initial imaging. The initial evaluation should also include a radiologic evaluation, with multi-phasic CTU (without and with intravenous contrast) being the imaging procedure of choice for asymptomatic microhematuria (AMH) in adults, as recommended by the American Urological Association guideline 1. However, for patients presenting with urethral discharge, the workup should prioritize the identification of potential infectious causes, with NAATs for STIs and urine culture being essential diagnostic tests. If the patient is sexually active, HIV, syphilis, and hepatitis testing should also be considered. A first-void urine sample (first 20-30 mL of urine) is preferred for STI testing as it contains the highest concentration of organisms. In some cases, a urethral swab may be necessary, and if symptoms persist despite negative STI testing, further evaluation with cystoscopy may be warranted to rule out urethral strictures, polyps, or malignancy. Imaging studies such as ultrasound or CT scan might be indicated if there is concern for urinary tract stones, prostate abnormalities, or other structural issues. Key considerations in the workup of hematuria with urethral discharge include:

• Thorough history and physical examination to identify potential causes and risk factors
• Urinalysis and serologic testing to evaluate for infection and other abnormalities
• NAATs for STIs and urine culture to identify potential infectious causes
• Imaging studies such as CTU or ultrasound to evaluate the urinary tract for structural issues or malignancy
• Cystoscopy to rule out urethral strictures, polyps, or malignancy if symptoms persist despite negative STI testing. The choice of imaging strategy should be individualized based on the patient's history, preferences, and available resources, with the goal of providing maximal diagnostic certainty while minimizing risk 1.

From the Research

Appropriate Workup for Hematuria with Urethral Discharge

The workup for hematuria (blood in urine) with urethral discharge involves several steps to determine the underlying cause of the symptoms.

• The initial evaluation should include a physical examination, medical history, and laboratory tests to identify possible reversible causes of hematuria and urethral discharge 2.
• A urinalysis should be performed to check for the presence of blood, white blood cells, and other abnormalities in the urine 2.
• If urethritis is suspected, a Gram stain of urethral secretions can be used to detect the presence of white blood cells and bacteria 3, 4.
• Nucleic acid amplification tests (NAAT) can be used to detect the presence of Chlamydia trachomatis, Neisseria gonorrhoeae, and other pathogens that can cause urethritis 4, 5, 6.
• The presence of hematuria may indicate a more serious underlying condition, such as a urinary tract infection or kidney stones, and further evaluation may be necessary to determine the cause of the hematuria 2.

Diagnostic Criteria for Urethritis

The diagnostic criteria for urethritis include:

• Typical signs and symptoms, such as dysuria, urethral discharge, and urethral discomfort 3, 4
• Mucopurulent urethral discharge 3, 4
• Gram stain of urethral secretions showing at least two white blood cells per oil immersion field 3
• First-void urinalysis showing at least 10 white blood cells per high-power field 3, 4
• Positive leukocyte esterase result with first-void urine 3

Treatment of Urethritis

The treatment of urethritis typically involves antibiotics, such as azithromycin or doxycycline, to target the underlying cause of the infection 3, 4, 6.

• The choice of antibiotic may depend on the suspected or confirmed pathogen, as well as the patient's medical history and allergies 3, 4.
• Patients with urethritis should be advised to abstain from sex until their symptoms have fully resolved and their partners have been adequately treated 3.