What to do for a 38-year-old man with microscopic hematuria (presence of blood in urine)?

Evaluation and Management of Microscopic Hematuria in a 38-Year-Old Man

A 38-year-old man with microscopic hematuria should undergo a complete urologic evaluation including cystoscopy and renal ultrasound to rule out serious underlying pathology, even at his relatively young age. 1

Initial Confirmation and Risk Stratification

• First, confirm microscopic hematuria with proper microscopic urinalysis:

  • Definition: ≥3 red blood cells per high-power field (RBC/HPF)
  • Requires confirmation in 2 of 3 properly collected specimens 1
  • Dipstick positivity alone is insufficient and requires microscopic confirmation

• Risk stratification according to AUA/SUFU guidelines:

  • This 38-year-old male falls into the intermediate risk category (age 40-59 for men) 1
  • Risk factors to assess:
    • Smoking history (pack-years)
    • Occupational exposure to chemicals
    • Family history of urologic malignancy
    • History of pelvic radiation

Diagnostic Evaluation

1. Laboratory tests:

   • Complete blood count
   • Serum creatinine and BUN
   • Examination of urinary sediment (look for dysmorphic RBCs, RBC casts)
   • 24-hour urine collection for protein quantification 1
   • Urine culture to rule out infection

2. Imaging:

   • Renal ultrasound is appropriate for this intermediate-risk patient 1
   • CT urography would be indicated if he were high-risk (>60 years old or >30 pack-years smoking)

3. Cystoscopy:

   • The AUA recommends cystoscopy for all patients ≥35 years with hematuria, regardless of risk level 1
   • This is crucial as cystoscopy has 87-100% sensitivity for detecting bladder cancer

Important Considerations

• Do not attribute hematuria to anticoagulation without evaluation:

  • If the patient is on antiplatelet or anticoagulant therapy, he still requires the same evaluation 1
  • Anticoagulation rarely causes hematuria without underlying pathology

• Assess for glomerular vs. non-glomerular source:

  • Glomerular indicators include dysmorphic RBCs, RBC casts, and significant proteinuria (>500-1000mg/24hr) 1
  • If glomerular source is suspected, consider nephrology referral

• Degree of hematuria does not correlate with severity:

  • The quantity of blood in urine does not reliably predict the seriousness of the underlying cause 2

Follow-up Management

• If initial evaluation is negative:

  • Repeat urinalysis at 6,12,24, and 36 months 1
  • Immediate re-evaluation if:
    • Recurrent gross hematuria
    • Abnormal urinary cytology
    • New irritative voiding symptoms

• If a non-malignant cause is identified:

  • Treat the underlying condition
  • Perform follow-up urinalysis after resolution to confirm absence of hematuria 1

Common Pitfalls to Avoid

1. Delaying or deferring evaluation:

   • Failing to thoroughly investigate hematuria may allow significant disease to progress 3
   • Even in younger patients, hematuria warrants proper evaluation

2. Relying on urinary cytology:

   • Urinary cytology should be eliminated from asymptomatic hematuria screening protocol 4
   • Not sensitive enough to obviate further workup if findings are negative

3. Assuming benign cause due to young age:

   • Studies have shown up to 20% incidence of urological malignancy in young adult men with significant microscopic hematuria 5

4. Neglecting leukocyturia without bacteriuria:

   • This may miss non-infectious causes 1

Remember that hematuria, even microscopic and without symptoms, should always trigger a thorough urologic investigation as it may indicate serious urologic disease that requires prompt diagnosis and treatment.