What is the treatment for a male presenting with hematuria (blood in urine)?

Treatment for Male Presenting with Hematuria

The treatment for a male presenting with hematuria requires prompt and thorough evaluation to identify the underlying cause, with immediate urologic referral mandatory for all patients with gross hematuria. 1

Initial Evaluation

History and Physical Examination

• Assess for:
  • Trauma history (pelvic fractures, straddle injuries)
  • Urinary symptoms (dysuria, frequency, urgency)
  • Risk factors for malignancy (age >60, smoking history, chemical exposures)
  • Medication use (anticoagulants, certain medications causing urine discoloration)
  • Recent infections
  • Pain (flank, suprapubic, urethral)

Laboratory Testing

• Complete blood count
• Serum creatinine and BUN
• Urinalysis with microscopic examination
• Urine culture if infection is suspected 1

Imaging and Diagnostic Workup

For Gross Hematuria

• CT Urography is the preferred initial imaging modality (sensitivity 92%, specificity 93%) 1
• If trauma is present with gross hematuria, contrast-enhanced CT with delayed scans is required 1
• Cystoscopy should be performed by a urologist for direct visualization 1

For Microscopic Hematuria (≥3 RBCs/HPF)

• Risk stratification based on:
  • RBC count
  • Age
  • Smoking history 1
• Imaging selection based on risk level:
  • Low risk: Consider renal ultrasound
  • Intermediate/high risk: CT Urography 1

Treatment Algorithm Based on Underlying Cause

1. Urinary Tract Infection

• Appropriate antibiotics based on culture results
• Follow-up urinalysis after treatment to confirm resolution 1

2. Trauma-Related Hematuria

• For renal injuries: Primarily non-operative management in most cases 2
• For bladder injuries:
  • Extraperitoneal ruptures: Non-operative management with catheter drainage
  • Intraperitoneal ruptures: Surgical repair 2
• For urethral injuries:
  • Anterior urethral injuries: Suprapubic or urethral drainage
  • Posterior urethral injuries: Secure catheter drainage of the bladder 2

3. Urolithiasis

• Medical expulsive therapy or surgical intervention depending on stone size and location 1

4. Benign Prostatic Hyperplasia

• Alpha-blockers for symptomatic relief
• 5α-reductase inhibitors for prostate size reduction
• Surgical intervention for severe cases 2

5. Malignancy

• Referral to urology for definitive management
• Treatment depends on type, stage, and grade of cancer 1

Special Considerations

Pelvic Fractures with Hematuria

• High risk for bladder rupture - CT cystography recommended 1
• Blood at urethral meatus requires retrograde urethrography before catheter placement 1

Penile Fracture

• Prompt surgical exploration and repair for acute signs and symptoms 2
• Evaluation for concomitant urethral injury if blood at meatus, gross hematuria, or inability to void 2

Testicular Trauma

• Scrotal exploration and debridement with tunical closure when possible 2

Follow-up and Surveillance

• For persistent asymptomatic microscopic hematuria after negative initial evaluation:

  • Low-risk patients: Annual urinalysis
  • Intermediate/high-risk patients: Urine cytology and repeat urinalysis at 6,12,24, and 36 months 1

• Even after negative initial evaluation, patients with a history of gross hematuria require surveillance 1

Important Caveats

1. Never dismiss self-limited gross hematuria - even a single episode warrants complete evaluation 1

2. Hematuria occurs intermittently - negative follow-up tests do not rule out serious pathology 3, 4

3. Degree of hematuria does not correlate with disease severity - even minimal hematuria can indicate serious underlying conditions 3, 4

4. Consider non-blood causes of red urine - certain medications, foods, or dyes can cause urine discoloration that mimics hematuria 5

5. Risk of malignancy with gross hematuria exceeds 10% - prompt urologic referral is essential 6