Management of Hematuria: Evaluation and Follow-Up Protocol
All patients with hematuria require a systematic evaluation to identify the underlying cause, with referral to urology indicated for all cases of gross hematuria, microscopic hematuria in patients aged ≥35 years, and patients with risk factors for urologic malignancy. 1
Initial Assessment and Differentiation
Diagnostic Workup
- Urinalysis with microscopic examination: Critical first step to distinguish between true hematuria, hemoglobinuria, and myoglobinuria 1
- Laboratory tests:
- Complete blood count with differential
- Basic metabolic panel including renal function
- Liver function tests
- Coagulation studies
- Urine culture and sensitivity 1
Differentiating Glomerular vs. Non-Glomerular Hematuria
- Glomerular hematuria: Characterized by dysmorphic RBCs, proteinuria, and cellular casts 1
- Non-glomerular hematuria: Normal-shaped RBCs without significant proteinuria or casts 1
Risk Stratification
The American Urological Association defines three risk categories for patients with hematuria 1:
- 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
Risk Factors for Urologic Malignancy
- Age >60 years
- Male gender
- Smoking history
- Exposure to industrial chemicals
- Family history of renal cancer
- History of pelvic radiation 1
Imaging Recommendations
- CT Urography: First-line imaging for detecting stones, renal/perirenal infections (92% sensitivity, 93% specificity) 1
- MR Urography: For patients with contrast allergy or renal insufficiency 1
- Renal Ultrasound: Alternative or for young patients (50% sensitivity, 95% specificity) 1
Referral Guidelines
Urology Referral Indicated For:
- All cases of gross hematuria (risk of malignancy >10%) 1, 2
- Microscopic hematuria in patients aged ≥35 years 1
- Persistent hematuria after treatment
- Age >60 years with unexplained hematuria
- Recurrent UTIs 1
Nephrology Referral Indicated For:
- Dysmorphic RBCs
- Proteinuria
- Cellular casts
- Renal insufficiency
- Suspected glomerular disease 1
Follow-Up Protocol
Low-Risk Patients:
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
Persistent Microscopic Hematuria:
- Continued surveillance is necessary as malignancies may develop later 1
- Consider nephrology referral, especially if proteinuria is present 1, 4
Special Considerations
Trauma-Related Hematuria
- Immediate evaluation with retrograde cystography if bladder injury is suspected 1
- IV contrast-enhanced abdominal/pelvic CT with immediate and delayed images for suspected renal injury 1
Pediatric Patients
- Prompt referral to pediatric nephrologist if:
- Hematuria does not resolve within 2 weeks of onset of glomerulonephritis
- Renal biopsy is needed
- Persistent microscopic hematuria is present 4
Common Pitfalls to Avoid
Dismissing microscopic hematuria: Even asymptomatic microscopic hematuria requires thorough evaluation 5, 2
Inadequate follow-up: Patients with negative initial workup but persistent hematuria should still be monitored 1, 6
Missing glomerular causes: Failing to recognize dysmorphic RBCs, proteinuria, or casts that suggest nephrologic rather than urologic disease 1
Overlooking medication-induced hematuria: Particularly from analgesics 4
Insufficient imaging: Using inadequate contrast volume for cystography (minimum 300 mL required) 1
The evidence strongly supports that patients who have undergone thorough initial negative investigations can be discharged from tertiary urologic care services if urinalysis becomes negative. However, those with persistent hematuria require continued surveillance, as they may be at risk for developing malignancy later 1, 3.