Treatment for Hematuria in Males
The treatment for hematuria in males must be guided by the underlying cause, with immediate urologic referral mandatory for all patients with gross hematuria, while microscopic hematuria requires risk stratification and appropriate evaluation to rule out urinary tract malignancy. 1
Initial Evaluation
Imaging
- CT Urography is the preferred initial imaging modality for patients with gross hematuria (sensitivity 92%, specificity 93%) 1
- MR Urography is an alternative for patients with contrast allergy or renal insufficiency 1
- Renal Ultrasound may be used as an alternative, particularly in younger patients, though it has lower sensitivity (50%) 1
- Upper urinary tract imaging is indicated in patients with:
- Hematuria (microscopic or macroscopic)
- History of urolithiasis
- Renal insufficiency
- Recent onset nocturnal enuresis 2
Laboratory Workup
- Complete blood count
- Serum creatinine and BUN
- Urinalysis with microscopic examination
- Urine culture if infection is suspected 1
Risk Stratification for Microscopic Hematuria
The American Urological Association stratifies patients into risk categories:
| Risk Level | Criteria |
|---|---|
| Low (0-0.4%) | 3-10 RBC/HPF + Age <60 years (women) or <40 years (men) + Non-smoker or <10 pack-years |
| Intermediate (0.2-3.1%) | 11-25 RBC/HPF or Age 60+ (women)/40-59 (men) or 10-30 pack-years smoking |
| High (1.3-6.3%) | >25 RBC/HPF or Age 60+ (men) or >30 pack-years smoking [1] |
Treatment Based on Underlying Cause
Urinary Tract Infection
- Treat with appropriate antibiotics based on culture
- Follow-up urinalysis after treatment to confirm resolution of hematuria 1
- If hematuria persists after appropriate antibiotic treatment, further diagnostic workup is warranted 3
Benign Prostatic Hyperplasia (BPH)
- Alpha-blockers or surgical intervention depending on severity 1
- Endoscopic evaluation may be helpful when considering treatment alternatives such as transurethral incision of the prostate or thermotherapy 2
Urolithiasis
- Medical expulsive therapy or surgical intervention based on stone size and location 1
Glomerular Disease
- ACE inhibitor or ARB therapy for blood pressure control and renal protection
- Moderate protein restriction to slow progression of renal disease 1
- Referral to nephrology for persistent glomerular hematuria 3
Urologic Referral
- Immediate urologic referral is mandatory for all patients with gross hematuria 1
- Cystoscopy should be performed by a urologist to directly visualize the bladder and urethra 1
- The AUA recommends cystoscopy for all patients ≥35 years with microscopic hematuria, particularly in high-risk patients 1
Follow-up and Surveillance
For patients with 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 Clinical Considerations
- Even a single episode of gross hematuria warrants complete evaluation 1
- The degree of hematuria does not correlate with the seriousness of its cause 4, 5
- Up to 5% of patients with asymptomatic microscopic hematuria may have a urinary tract malignancy 3
- Risk factors for urinary malignancy include age >60 years, male gender, smoking history, exposure to industrial chemicals, family history of renal cancer, and history of pelvic radiation 1
Common Pitfalls to Avoid
- Dismissing self-limited gross hematuria - Even a single episode warrants complete evaluation 1
- Inadequate imaging - Plain radiographs have only 59% sensitivity for stone detection and are insufficient 1
- Failing to follow up after treatment - Persistent hematuria after treating a presumed cause requires further evaluation 3
- Overlooking microscopic hematuria - Though often benign, microscopic hematuria can indicate serious underlying pathology 6