What is the initial workup for a patient presenting with gross hematuria?

Workup for Gross Hematuria

Patients presenting with gross hematuria require immediate and thorough evaluation due to the >10% risk of malignancy, including comprehensive history, physical examination, laboratory testing, imaging, and cystoscopy. 1, 2

Initial Evaluation

History and Physical Examination

• Assess risk factors for genitourinary malignancy:
  • Age (men ≥60 years, women ≥60 years)
  • Smoking history (quantify pack-years)
  • Occupational/environmental exposures
  • Family history of urologic malignancies
• Evaluate for other causes:
  • Recent trauma
  • Flank pain (suggests stones or pyelonephritis)
  • Irritative urinary symptoms
  • Medications (anticoagulants, aspirin)
  • Previous urologic conditions

Laboratory Testing

1. Urinalysis with microscopic examination - critical to distinguish between true hematuria, hemoglobinuria, and myoglobinuria 1

   • Assess RBC morphology (dysmorphic RBCs suggest glomerular disease)
   • Look for RBC casts (indicative of glomerular pathology)
   • Check for pyuria (suggests infection)

2. Additional laboratory tests:

   • Complete blood count with differential
   • Basic metabolic panel including serum creatinine
   • Urine culture and sensitivity
   • Urine cytology (for high-risk patients)
   • Coagulation studies if on anticoagulants
   • Protein-to-creatinine ratio (significant if >0.2 g/g)

Imaging Studies

1. CT urography - first-line imaging for most patients with gross hematuria (92% sensitivity, 93% specificity) 1

   • Provides comprehensive evaluation of kidneys, ureters, and bladder
   • Can detect stones, masses, and other abnormalities

2. Alternative imaging options:

   • MR urography or ultrasound for patients with renal insufficiency or contrast allergy
   • Renal ultrasound for younger patients (<40 years) with lower risk profiles

Specialist Referral

• Urology referral is mandatory for all patients with gross hematuria 1, 2

  • Cystoscopy is essential to evaluate the bladder and urethra
  • Should be performed promptly due to high risk of malignancy

• Nephrology referral indicated if:

  • Protein excretion >1 g/day
  • Persistent significant proteinuria
  • Abnormal renal function
  • Dysmorphic RBCs and RBC casts suggesting glomerular disease

Risk Stratification

The American Urological Association defines three risk categories for patients with hematuria 3, 1:

• Low risk (0-0.4% malignancy risk)
• Intermediate risk (0.2-3.1% malignancy risk)
• High risk (1.3-6.3% malignancy risk)

Risk factors that increase concern for malignancy include:

• Age >60 years (especially in men)
• Smoking history >30 pack-years
• Gross hematuria (versus microscopic)
• Male gender
• History of pelvic radiation

Follow-up and Surveillance

• For patients with identified pathology, treatment should be directed at the specific cause
• For patients with negative evaluations:
  • Low-risk: Annual urinalysis
  • Intermediate/high-risk: Urine cytology and repeat urinalysis at 6,12,24, and 36 months

Common Pitfalls to Avoid

1. Delaying evaluation - Gross hematuria warrants prompt and thorough investigation 4
2. Attributing hematuria solely to anticoagulant therapy - Even patients on anticoagulants require complete evaluation, as studies show malignancy in 18-25% of these patients 5
3. Inadequate imaging - CT urography is superior to ultrasound and IVP for detecting urinary tract malignancies
4. Neglecting cystoscopy - Most cancers diagnosed among persons with hematuria are bladder cancers, optimally detected with cystoscopy 3
5. Failure to risk stratify - Evaluation should be tailored based on risk factors for malignancy

The evidence clearly demonstrates that gross hematuria requires comprehensive evaluation regardless of anticoagulant use or other potential explanations, as delays in diagnosis of bladder cancer can increase cancer-specific mortality by 34% 3.