What is the next step in managing a patient with hematuria?

Management of Hematuria

All patients with hematuria require risk stratification and appropriate evaluation, with gross hematuria warranting immediate urologic referral due to the high risk of underlying malignancy (>10%). 1, 2

Initial Assessment and Risk Stratification

The American Urological Association (AUA) and Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) guidelines categorize patients with hematuria into risk groups:

• High risk: Age >60 years, male gender, smoking history, exposure to industrial chemicals, family history of renal cancer, history of pelvic radiation 1
• Intermediate risk: Risk factors between high and low
• Low risk: Minimal risk factors, younger patients

Diagnostic Approach

For Gross Hematuria:

• Immediate urologic referral is mandatory, even if self-limited 3, 1
• Imaging: CT urography is preferred; renal and bladder ultrasound can be used as initial screening if CT is not immediately available 1
• Cystoscopy: Required for all patients with gross hematuria 1

For Microscopic Hematuria:

1. Confirm with microscopy: ≥3 RBCs per high-powered field 3
2. Rule out benign causes: UTI, menstruation, vigorous exercise, trauma
3. If no benign cause is identified: Consider urology referral for cystoscopy and imaging 3

Imaging Recommendations

Clinical Scenario	Recommended Imaging	Sensitivity	Specificity
Most cases	CT urography	92%	93%
Renal insufficiency or contrast allergy	MR urography or ultrasound	High	High
Young patients (<40 years)	Renal ultrasound	50%	95%

Follow-up and Surveillance

• After negative evaluation: The 2025 AUA/SUFU guidelines recommend shared decision-making regarding whether to repeat urinalysis in the future 3
• For persistent hematuria with negative evaluation: Consider repeat evaluation based on risk factors and clinical changes 3
• Important note: Even after a negative evaluation, changes in clinical status (new gross hematuria, worsening symptoms) warrant further evaluation 3

Key Pitfalls to Avoid

1. Do not ignore gross hematuria: Even a single episode requires complete evaluation 1, 2
2. Do not attribute hematuria solely to anticoagulation therapy: Pursue evaluation even in patients on antiplatelet or anticoagulant therapy 3
3. Do not use urinary cytology or urine-based molecular markers in the initial evaluation of hematuria 3
4. Do not perform screening urinalysis for cancer detection in asymptomatic adults 3
5. Do not discharge patients without follow-up plan: The 2025 AUA/SUFU guidelines emphasize shared decision-making regarding future monitoring 3

Special Considerations

• Delays in evaluation of gross hematuria can increase cancer-specific mortality by 34% 1
• Young patients (<40 years) with microscopic hematuria have lower risk of malignancy but should still receive appropriate evaluation 4
• Persistent unexplained hematuria despite negative initial evaluation may require repeat testing at intervals 3, 1

The 2025 AUA/SUFU guidelines note that most patients with a negative hematuria evaluation do not require ongoing urologic monitoring and may be safely discharged after shared decision-making, though select high-risk patients may benefit from follow-up 3.