What is the evaluation and management approach for hematuria?

Evaluation and Management of Hematuria

All patients with hematuria should undergo a thorough diagnostic evaluation, with gross hematuria requiring immediate urologic referral due to high risk of underlying malignancy. 1

Definition and Initial Assessment

• Microscopic hematuria: ≥3 red blood cells per high-power field on microscopic evaluation from two of three properly collected urinalysis specimens 1
• Gross hematuria: Visible blood in urine, requires immediate urologic evaluation even if self-limited 1
• Important: Dipstick positivity for blood must always be confirmed with microscopic examination due to limited specificity (65-99%) 1

Risk Stratification

The American Urological Association defines three risk categories for patients with hematuria:

Risk Level	Cancer Risk	Factors
Low	0-0.4%	Younger age, no risk factors
Intermediate	0.2-3.1%	Some risk factors present
High	1.3-6.3%	Age >60, smoking history, high RBC count

Major Risk Factors for Urologic Malignancy

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

Diagnostic Algorithm

1. Initial Laboratory Workup:

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

2. Imaging Based on Risk:

   • CT Urography (preferred): 92% sensitivity, 93% specificity for detecting stones, renal/perirenal infections, and malignancies 1
   • MR Urography: Alternative for patients with contrast allergy or renal insufficiency
   • Renal Ultrasound: Alternative or in young patients (50% sensitivity, 95% specificity) 1

3. Additional Evaluation:

   • Cystoscopy for evaluation of lower urinary tract
   • Retrograde cystography (mandatory for patients with gross hematuria and pelvic fracture, requiring minimum 300mL contrast) 1
   • Consider urodynamic evaluation if upper and lower tract evaluations are unremarkable 1

Management Approach by Risk Category

Low Risk Patients

• Annual urinalysis for follow-up 1
• Consider nephrological evaluation if glomerular cause is suspected

Intermediate/High Risk Patients

• Urine cytology and repeat urinalysis at 6,12,24, and 36 months 1
• Surveillance with repeat imaging and cystoscopy for patients with history of gross hematuria 1

Special Considerations

• Patients on antiplatelet or anticoagulant therapy should still be referred for urologic evaluation, as these medications rarely cause hematuria without underlying pathology 1
• Patients with isolated glomerular hematuria require follow-up at six-month intervals due to elevated risk for renal disease 2

Common Pitfalls to Avoid

• Relying solely on dipstick testing without microscopic confirmation 1
• Using only ultrasound for trauma patients with gross hematuria 1
• Using inadequate contrast volume for cystography (minimum 300mL needed) 1
• Collecting urine samples from extension tubing or collection bag (obtain after changing catheter) 1
• Dismissing trace or 1+ hematuria as clinically insignificant, especially in high-risk patients 1
• Assuming anticoagulation therapy is an adequate explanation for hematuria 1

Treatment

Treatment depends on the underlying cause:

• Antibiotics for urinary tract infections
• Medical expulsive therapy or surgical intervention for urolithiasis
• Alpha-blockers or surgical intervention for benign prostatic hyperplasia 1
• Targeted therapy for specific glomerular causes if identified