What is the initial workup for a patient presenting with gross hematuria?

Workup of Gross Hematuria

The initial workup for a patient presenting with gross hematuria should include a complete urologic evaluation with CT urography and cystoscopy due to the >10% risk of urinary tract malignancy. 1, 2

Initial Risk Assessment

• Gross hematuria requires prompt and thorough evaluation regardless of other symptoms or risk factors
• Risk factors for urinary tract malignancy:
  • Age >60 years
  • Male gender
  • Smoking history (especially >30 pack-years)
  • Exposure to industrial chemicals
  • Family history of renal cancer
  • History of pelvic radiation 1

Laboratory Evaluation

1. Complete blood count - assess for anemia and infection
2. Serum creatinine and BUN - evaluate renal function
3. Urinalysis with microscopic examination - confirm hematuria and assess for other abnormalities
4. Urine culture - if infection is suspected 1

Imaging Studies

• CT Urography is the preferred initial imaging modality (sensitivity 92%, specificity 93%) 1

  • Must be performed with intravenous contrast unless contraindicated 3
  • Evaluates kidneys, ureters, and bladder for masses, stones, and structural abnormalities

• Alternative imaging options if CT is contraindicated:

  • MR Urography - for patients with contrast allergy or renal insufficiency
  • Renal Ultrasound - lower sensitivity (50%) but high specificity (95%) 1

Specialist Referral

• Immediate urology referral is mandatory for all patients with gross hematuria 1, 2
• Cystoscopy should be performed by a urologist to directly visualize the bladder and urethra 1

Special Considerations

• Trauma patients with gross hematuria require contrast-enhanced CT 3

  • If renal injury is detected, delayed scans should be obtained to evaluate collecting system disruption 3

• Patients with pelvic fractures and gross hematuria are at high risk for bladder rupture 3

  • CT cystography is recommended (CT of pelvis after retrograde distention of bladder with contrast) 3

• Blood at urethral meatus (especially with pelvic fractures or straddle injury) requires:

  • Retrograde urethrography before bladder catheter placement
  • Consider cystogram to exclude concomitant bladder injury 3

Common Pitfalls to Avoid

1. Dismissing self-limited gross hematuria - Even a single episode warrants complete evaluation 1

2. Inadequate imaging - Plain radiographs have only 59% sensitivity for stone detection and are insufficient for evaluation 3

3. Delaying urologic referral - Prompt referral is essential as risk of malignancy with gross hematuria exceeds 10% 2

4. Incomplete follow-up - Even after negative initial evaluation, patients with history of gross hematuria require surveillance 1

5. Attributing hematuria solely to anticoagulation - Patients on antiplatelet or anticoagulant therapy still require complete evaluation 1

Remember that delaying or deferring thorough investigation of gross hematuria may permit significant disease processes to become more extensive, potentially compromising morbidity and mortality outcomes 4.