What is the appropriate management for a patient with macroscopic hematuria?

Management of Macroscopic Hematuria

Macroscopic hematuria requires prompt evaluation with renal and bladder ultrasound as first-line imaging, followed by risk-stratified assessment including cystoscopy for patients with risk factors for malignancy. 1

Initial Assessment and Risk Stratification

Macroscopic hematuria carries a significant risk of underlying malignancy (>10%) and requires thorough evaluation 2. Risk factors that increase concern for malignancy include:

• Age >60 years
• Male gender
• Smoking history (especially >30 pack-years)
• Exposure to industrial chemicals
• Family history of renal cancer
• History of pelvic radiation 1

The American Urological Association defines three risk categories:

• Low risk (0-0.4% malignancy risk)
• Intermediate risk (0.2-3.1% malignancy risk)
• High risk (1.3-6.3% malignancy risk) 1

Diagnostic Algorithm

Step 1: Initial Laboratory Evaluation

• Urinalysis with microscopic examination to:
  • Confirm true hematuria (vs. hemoglobinuria/myoglobinuria)
  • Assess RBC morphology (dysmorphic RBCs suggest glomerular disease)
  • Look for RBC casts and pyuria
• Complete blood count
• Basic metabolic panel including renal function
• Coagulation studies
• Urine culture and sensitivity 1

Step 2: Imaging

• First-line imaging: Renal and bladder ultrasound

  • Appropriate initial test for all patients with macroscopic hematuria
  • Can identify renal masses, bladder lesions, and urolithiasis 3, 1

• Second-line imaging (based on risk factors and initial findings):

  • CT urography (92% sensitivity, 93% specificity) for patients with:
    • Age >40 years
    • Risk factors for malignancy
    • Persistent unexplained hematuria 1
  • MR urography if renal insufficiency or contrast allergy 1

Step 3: Specialist Referral and Advanced Evaluation

• Urology referral for:

  • All patients with macroscopic hematuria
  • Patients >40 years
  • Smoking history
  • Persistent hematuria after treatment of infection 1, 2

• Cystoscopy:

  • Essential for evaluation of bladder and urethra
  • Should be performed promptly due to high risk of malignancy
  • Most cancers diagnosed among persons with hematuria are bladder cancers 1, 4

• Nephrology referral if:

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

Management Considerations

For Acute Presentations

• Ensure hemodynamic stability
• Continuous bladder irrigation for clot retention
• Consider hospitalization for:
  • Clot retention
  • Cardiovascular instability
  • Uncontrolled pain
  • Sepsis
  • Acute renal failure
  • Coagulopathy
  • Severe comorbidity
  • Heavy hematuria 5

For Specific Etiologies

• Urinary tract infection: Appropriate antibiotics based on culture
• Urolithiasis: Pain management, hydration, possible urological intervention
• Trauma: IV contrast-enhanced CT for suspected renal injury; non-invasive management for hemodynamically stable patients; immediate intervention (surgery or angioembolization) for unstable patients 1

Follow-up and Surveillance

• For patients with identified and treated causes:

  • Repeat urinalysis to confirm resolution

• For patients with negative evaluations:

  • Low-risk patients: Annual urinalysis
  • Intermediate/high-risk patients: Urine cytology and repeat urinalysis at 6,12,24, and 36 months 1

Important Cautions

• Never attribute hematuria solely to anticoagulant therapy - studies show malignancy in 18-25% of these patients 1
• Delays in evaluation of gross hematuria can increase cancer-specific mortality by 34% 1
• A single episode of hematuria is equally concerning as recurrent episodes 5
• Even if initial evaluation is negative, continued surveillance is necessary as malignancies may develop later 1