What are the next steps for a patient with resolved gross hematuria?

Management of Resolved Gross Hematuria

Patients with resolved gross hematuria require a complete urologic evaluation including risk stratification, cystoscopy, and appropriate imaging to rule out underlying malignancy, regardless of resolution of symptoms. 1

Initial Assessment

After resolution of gross hematuria on continuous bladder irrigation (CBI), the following steps should be taken:

1. Risk stratification based on:

   • Age (>60 years increases risk)
   • Sex (male gender increases risk)
   • Smoking history
   • Exposure to industrial chemicals
   • Family history of urologic malignancy
   • History of pelvic radiation 1

2. Laboratory evaluation:

   • Repeat urinalysis to confirm resolution of hematuria
   • Urine culture to rule out infection
   • Serum creatinine and BUN to assess renal function
   • Complete blood count 1

Diagnostic Workup

Imaging

• CT urography is the primary recommended imaging modality (sensitivity 92%, specificity 93%) 1
• MR urography for patients with contrast allergy or renal insufficiency
• Renal ultrasound may be used as an alternative in young, low-risk patients 1

Cystoscopy

• Mandatory for all patients with gross hematuria regardless of resolution, with sensitivity ranging from 87% to 100% for detecting bladder cancer 1
• Should be performed even if imaging is normal, as small bladder lesions may not be visible on imaging studies

Follow-up Protocol

• If evaluation is negative but risk factors exist:

  • Repeat urinalysis at 6,12,24, and 36 months 1
  • Immediate re-evaluation if recurrent gross hematuria, abnormal urinary cytology, or new irritative voiding symptoms occur

• If a non-malignant cause is identified:

  • Treat the underlying condition
  • Perform follow-up urinalysis after resolution to confirm absence of hematuria 2
  • If hematuria persists despite treatment, perform risk-based urologic evaluation 2

Important Considerations

• Anticoagulation status does not change the evaluation protocol - patients on antiplatelet agents or anticoagulants require the same evaluation as those not on these medications 2

• Do not assume resolution means benign etiology - gross hematuria carries a >10% risk of underlying malignancy even if it resolves spontaneously 1, 3

• Do not delay evaluation - prompt and thorough investigation is essential, as delaying may permit a significant disease process to become more extensive 4

Common Pitfalls to Avoid

• Assuming resolution equals no pathology - gross hematuria requires complete evaluation even after resolution 1, 4

• Inadequate follow-up - failing to monitor patients after initial negative workup 5

• Incomplete evaluation - not performing both cystoscopy and appropriate imaging in high-risk patients 1

• Attributing hematuria solely to anticoagulation - anticoagulation may exacerbate bleeding but rarely causes it without underlying pathology 1