Does a 70-year-old male with hematuria (Occult Blood 1+) require a urologic evaluation?

Urologic Evaluation for a 70-Year-Old Male with Hematuria

A 70-year-old male with 1+ occult blood on urinalysis requires prompt urologic referral due to the high risk of underlying urinary tract malignancy. 1

Risk Assessment and Rationale

The patient presents with several significant risk factors that warrant urologic evaluation:

• Age >60 years: Advanced age significantly increases risk of urologic malignancy 1
• Male gender: Men have higher risk of bladder cancer 2
• Positive occult blood (1+): Any degree of hematuria in this demographic requires evaluation 1

The American Urological Association (AUA) and other guidelines consistently recommend urologic referral for patients with hematuria who are older than 60 years, as this finding could indicate serious underlying pathology including malignancy 2, 1. The U.K. National Institute for Health and Clinical Excellence specifically identifies unexplained hematuria in patients older than 60 years as a trigger for "suspected cancer pathway" referral for an appointment within 2 weeks 2.

Diagnostic Algorithm

1. Confirm microscopic hematuria with microscopic examination of urine sediment

   • The threshold of ≥3 RBCs per high-powered field is the standard definition 1
   • A single positive result is sufficient to proceed with evaluation 2

2. Laboratory evaluation

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

3. Imaging studies

   • CT Urography is the preferred imaging modality (92% sensitivity, 93% specificity) 1
   • Alternative options for patients with contraindications:
     • MR Urography (for contrast allergy or renal insufficiency)
     • Renal ultrasound (lower sensitivity at 50%) 1

4. Cystoscopy

   • Essential component of the evaluation to visualize the lower urinary tract 1

Important Considerations

• Do not delay referral to complete all testing, as this can be coordinated with urology 1
• Anticoagulation is not an adequate explanation for hematuria - these medications may exacerbate bleeding but rarely cause it without underlying pathology 1
• Avoid relying solely on dipstick testing without microscopic confirmation 1
• Do not dismiss trace or 1+ hematuria as clinically insignificant, especially in high-risk patients 2, 3

Follow-up Recommendations

For a 70-year-old male with hematuria, the patient would be classified as high-risk (1.3-6.3% risk of malignancy) based on AUA risk stratification 1. After initial evaluation:

• If a malignancy is found, appropriate cancer treatment protocols should be followed
• If no malignancy is found, surveillance should include:
  • Urine cytology and repeat urinalysis at 6,12,24, and 36 months 1
  • Consideration for repeat imaging and cystoscopy based on risk factors 1

The risk of urinary tract cancer in men over 50 years with hematuria has been documented to be significant, with studies showing that even intermittent hematuria can indicate serious underlying pathology 4. Delaying or deferring investigation of hematuria in this high-risk population could allow a significant disease process to progress 5.