Management of Frank Hematuria
If you have frank hematuria (visible blood in urine), you should seek immediate urologic evaluation, as this condition has a relatively high risk (>10%) of underlying cancer or other clinically significant conditions. 1, 2
Initial Steps
- Immediate medical attention: Frank (visible) hematuria requires prompt evaluation, even if it's self-limited or occurs only once
- Do not delay evaluation: Delays in assessment of gross hematuria can increase cancer-specific mortality by 34% 2
- Continue evaluation even if on blood thinners: Antiplatelet or anticoagulant therapy does not explain away hematuria and should not prevent thorough investigation 1
Diagnostic Workup
Imaging
- First-line imaging: Renal and bladder ultrasound should be performed as the initial screening tool 2
- Additional imaging based on clinical presentation:
- If acute flank pain is present: CT urography (92% sensitivity, 93% specificity)
- If renal insufficiency or contrast allergy exists: MR urography or ultrasound
- For younger patients: Renal ultrasound may be sufficient 2
Specialist Referral
- Urology referral: Required for all patients with frank hematuria for cystoscopy and comprehensive evaluation 1, 2
- Nephrology referral: Indicated if there are signs of kidney dysfunction (eGFR <60 ml/min/1.73m²), presence of dysmorphic RBCs, RBC casts, or significant proteinuria 2
Risk Stratification
The American Urological Association defines three risk categories for malignancy in patients with macroscopic hematuria 2:
- 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:
- Age >60 years
- Male gender
- Smoking history
- Exposure to industrial chemicals
- Family history of renal cancer
- History of pelvic radiation 2
What to Avoid
- Do not ignore even a single episode: A single episode of hematuria is equally concerning as recurrent episodes 2
- Do not rely on urinary cytology initially: Clinicians should not obtain urinary cytology or other urine-based molecular markers for bladder cancer detection in the initial evaluation 1
- Do not assume benign causes without confirmation: Even seemingly obvious causes like UTI should be confirmed to have resolved with follow-up testing 2
Follow-up
- After treatment of identified 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 2
Important Caution
Delaying or deferring a thorough investigation of frank hematuria may allow a significant disease process to progress. The risk of underlying cancer with frank hematuria is consistently >10% and can be >25% in some cases 1, 3. Even if initial evaluation is negative, continued surveillance is essential.