From the Guidelines
For a 70-year-old male with gross hematuria and a history of smoking, I recommend an urgent and comprehensive workup to rule out urological malignancy, particularly bladder cancer. This recommendation is based on the strong association between smoking, advanced age, and urological malignancies, as highlighted in the study by Wolfman et al 1. The patient's age and smoking history significantly increase the risk of bladder cancer, making prompt evaluation crucial.
Initial Evaluation
The workup should begin with a detailed history and physical examination, focusing on:
- Duration of hematuria
- Associated symptoms like dysuria or flank pain
- Quantifying smoking history in pack-years
Laboratory Tests
Order the following laboratory tests:
- Urinalysis to confirm hematuria and check for infection
- Urine culture to rule out infection
- Complete blood count and comprehensive metabolic panel to assess kidney function and rule out coagulopathy
Imaging Studies
Imaging studies should include a CT urogram (with contrast if kidney function permits) to evaluate the entire urinary tract for masses, stones, or structural abnormalities, as recommended by the American College of Radiology 1.
Urology Referral
Given the patient's age and smoking history, prompt referral to urology for cystoscopy is essential, ideally within 2-4 weeks. This direct visualization of the bladder is crucial for detecting bladder tumors, as emphasized by the American College of Physicians 1.
Follow-up
If the initial workup is negative but hematuria persists, consider repeat evaluation in 3-6 months. The urgency of this workup is justified by the strong association between smoking, advanced age, and urological malignancies, particularly bladder cancer, where early detection significantly improves outcomes.
From the Research
Workup for Gross Hematuria
The workup for a 70-year-old male patient with gross hematuria and a history of smoking includes:
- A thorough history and physical examination to determine potential causes and assess risk factors for malignancy 2, 3, 4, 5
- Laboratory tests to rule out intrinsic renal disease 2, 6, 5
- Imaging of the urinary tract, such as intravenous pyelography, sonography, or computed tomography urography 3, 6, 4, 5
- Cystoscopy to evaluate the bladder and urethra 3, 6, 4, 5
- Urine cytology to check for abnormal cells 3, 4, 5
Risk Factors and Recommendations
The patient's age and history of smoking increase the risk of malignancy, and prompt urologic referral is recommended 2, 4
- The American Urological Association best practice policy recommends complete urologic evaluation for all patients with gross hematuria, regardless of age 4
- A risk-adapted diagnostic strategy should be used to evaluate the patient, taking into account their individual risk factors and medical history 5
Follow-up and Monitoring
Even if the patient has a negative workup, guidelines recommend that primary care physicians follow the patient semi-annually for 3 years 6
- Patients with isolated glomerular hematuria are at elevated risk for renal disease and should undergo follow-up checks at six-month intervals 5