What are the next steps for a 76-year-old male with visible hematuria (blood in urine) who is asymptomatic?

Management of Visible Hematuria in a 76-Year-Old Asymptomatic Male

All patients with visible (gross) hematuria should be promptly referred for urologic evaluation, regardless of whether the bleeding is self-limited, due to the high risk of underlying malignancy (>10%). 1, 2

Initial Assessment in Primary Care

1. Confirm the presence of hematuria:

   • Perform urinalysis with microscopic examination to confirm hematuria
   • Document number of RBCs per high-power field
   • Do not rely solely on dipstick testing (specificity only 65-99%) 1

2. Risk stratification:

   • This 76-year-old male is automatically in the high-risk category due to:
     • Age >60 years
     • Male gender
     • Visible (gross) hematuria 1

3. Initial laboratory workup:

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

Urgent Referral Process

• Refer for urologic evaluation immediately, even if hematuria is self-limited 3
• Do not delay referral to complete all testing - this can be coordinated with urology
• Do not obtain urinary cytology or other urine-based molecular markers for bladder cancer detection in the initial evaluation 3

Important Considerations

• Pursue evaluation even if patient is on antiplatelet or anticoagulant therapy 3

  • Common misconception: Anticoagulation is not an adequate explanation for hematuria
  • Medications may exacerbate bleeding but rarely cause it without underlying pathology

• Risk of malignancy:

  • Visible hematuria carries >10% risk of urologic malignancy in this age group 2
  • Risk factors present: age >60 years and male gender 1

Expected Urologic Evaluation

The urologic evaluation will likely include:

1. Comprehensive imaging:

   • CT Urography (preferred) with contrast enhancement (sensitivity 92%, specificity 93%) 1
   • Alternative imaging if contraindicated:
     • MR Urography (for patients with contrast allergy or renal insufficiency)
     • Renal ultrasound (less sensitive at 50% but 95% specific) 1

2. Cystoscopy:

   • Direct visualization of bladder and urethra
   • Essential for detecting bladder cancer and other lower urinary tract pathologies 1

Common Pitfalls to Avoid

• Do not delay referral while completing the workup - this can lead to delayed diagnosis of potentially curable malignancy 4
• Do not attribute hematuria solely to anticoagulant/antiplatelet medications without proper evaluation 3
• Do not rely on ultrasound alone as it has limited sensitivity (50%) for detecting urinary tract malignancies 1
• Do not dismiss self-limited episodes of gross hematuria - they warrant the same thorough evaluation 3, 4

Remember that delaying or deferring a careful investigation of visible hematuria may permit a significant disease process to progress 4.