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

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Initial Workup for Hematuria

The initial workup for hematuria should include urinalysis with microscopic examination, complete blood count, serum creatinine and BUN, and risk stratification to determine the need for imaging and specialist referral. 1

Risk Stratification

Proper risk assessment is crucial for determining the appropriate diagnostic pathway:

Risk Factors for Urinary Tract Malignancy

  • Age >60 years
  • Male gender
  • Smoking history
  • Exposure to industrial chemicals
  • Family history of renal cancer
  • History of pelvic radiation 1

Risk Categories (per AUA guidelines)

  • Low risk: 0-0.4% risk of malignancy
  • Intermediate risk: 0.2-3.1% risk of malignancy
  • High risk: 1.3-6.3% risk of malignancy 1

Diagnostic Algorithm

Step 1: Initial Laboratory Evaluation

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

Step 2: Classify Hematuria Type

  • Gross hematuria: Visible blood in urine

    • Risk of malignancy >10% 2
    • Requires immediate urologic referral 2

  • Microscopic hematuria:

    • Asymptomatic: >3 RBCs/HPF on 2 of 3 properly collected urinalyses
    • Symptomatic: >3 RBCs/HPF on 2 of 3 properly collected urinalyses 3
    • High-grade: >50 RBCs/HPF on a single urinalysis 3

Step 3: Imaging Selection Based on Risk

  • CT Urography: Preferred imaging modality (sensitivity 92%, specificity 93%) 1

    • Indicated for intermediate and high-risk patients
    • Should include contrast enhancement unless contraindicated

  • Alternative Imaging:

    • MR Urography: For patients with contrast allergy or renal insufficiency
    • Renal Ultrasound: Alternative or for young patients (sensitivity 50%, specificity 95%) 1

Step 4: Specialist Referral

  • Urology referral indicated for:

    • All patients with gross hematuria
    • High-grade hematuria (>50 RBCs/HPF) on a single urinalysis
    • Asymptomatic microscopic hematuria (>3 RBCs/HPF on 2 of 3 urinalyses)
    • Symptomatic hematuria (>3 RBCs/HPF on 2 of 3 urinalyses) 3

  • Nephrology referral: Consider if intrinsic renal disease is suspected (proteinuria, dysmorphic RBCs, cellular casts, or renal insufficiency) 2

Common Causes of Hematuria

Benign Causes

  • Urinary tract infection
  • Benign prostatic hyperplasia
  • Urinary calculi 2
  • Renal hemangiomas (particularly in young patients) 4

Serious Causes

  • Bladder cancer
  • Renal cancer
  • Intrinsic renal disease 2

Follow-up Recommendations

  • Low-risk patients: Annual urinalysis 1
  • Intermediate/high-risk patients:
    • Urine cytology and repeat urinalysis at 6,12,24, and 36 months
    • Surveillance with repeat imaging and cystoscopy for high-risk patients with a history of gross hematuria 1

Important Pitfalls to Avoid

  • Do not rely solely on ultrasound for trauma patients with gross hematuria as injuries may be missed 1
  • Do not collect urine samples from extension tubing or collection bag - obtain after changing catheter 1
  • Do not dismiss gross hematuria - it requires immediate urologic referral due to high risk of malignancy (>10%) 2
  • Do not use voided urinary cytology for asymptomatic hematuria screening - it lacks sufficient sensitivity to rule out malignancy 3

References

1
Guideline

Urinary Tract Imaging Guidelines

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

2
Research

Hematuria.

Primary care, 2019

4
Research

Ureteroscopy for benign hematuria.

The Urologic clinics of North America, 2004

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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