What is the management for significant hematuria?

Management of Significant Hematuria

Patients with significant hematuria (Large 250ery/uL 3+) should be promptly referred for urologic evaluation, especially if gross hematuria is present, due to the high risk of underlying malignancy. 1

Initial Evaluation

• Confirm hematuria: Dipstick positivity for blood should always be confirmed with microscopic examination due to limited specificity (65-99%) 1
• Definition: Microscopic hematuria is defined as ≥3 red blood cells per high-power field on microscopic evaluation from two of three properly collected specimens 1
• Risk stratification: Assess for risk factors that increase likelihood of malignancy:
  • Age >60 years
  • Male gender
  • Smoking history
  • Exposure to industrial chemicals
  • Family history of renal cancer
  • History of pelvic radiation 1

Diagnostic Workup

Laboratory Tests

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

Imaging

• CT Urography is the preferred imaging modality (sensitivity 92%, specificity 93%) 1, 2

  • Should include unenhanced scan, nephrographic phase, and excretory phase 2
  • Must include contrast enhancement unless contraindicated 1

• Alternative imaging if CT is contraindicated:

  • MR Urography: For patients with contrast allergy or renal insufficiency
  • Renal Ultrasound: Lower sensitivity (50%) but high specificity (95%) 1

Additional Diagnostic Tests

• Cystoscopy: Mandatory for evaluation of lower urinary tract 1
• Retrograde cystography: Required for patients with gross hematuria and pelvic fracture (minimum 300mL contrast) 1
• Urine cytology: Particularly important for high-risk patients 1

Management Based on Risk Categories

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

1. High-Risk Patients (1.3-6.3% risk of malignancy)

• Gross hematuria (>10% risk of malignancy)
• Age >60 years
• Significant smoking history
• Occupational exposures
• Management:
  • Immediate urologic referral
  • Complete upper and lower tract evaluation
  • Surveillance with repeat imaging and cystoscopy 1, 3

2. Intermediate-Risk Patients (0.2-3.1% risk)

• Management:
  • Urologic referral
  • Urine cytology and repeat urinalysis at 6,12,24, and 36 months 1

3. Low-Risk Patients (0-0.4% risk)

• Management:
  • Annual urinalysis for follow-up 1

Treatment of Underlying Causes

Treatment depends on the specific etiology:

• Urinary tract infections: Appropriate antibiotics
• Urolithiasis: Medical expulsive therapy or surgical intervention
• Benign prostatic hyperplasia: Alpha-blockers or surgical intervention
• Malignancy: Referral for oncologic management 1, 4

Common Pitfalls to Avoid

• Relying solely on dipstick testing without microscopic confirmation 1
• Dismissing trace or 1+ hematuria as clinically insignificant, especially in high-risk patients 1
• Attributing hematuria to anticoagulant therapy without further evaluation - anticoagulation may exacerbate bleeding but rarely causes it without underlying pathology 1
• Using inadequate contrast volume for cystography (minimum 300mL needed) 1
• Delaying evaluation of hematuria, which may permit significant disease processes to become more extensive 5

Even if the initial workup is negative, guidelines recommend that patients be followed semi-annually for 3 years to ensure no pathology was missed 4.