From the Guidelines
The next step in diagnosing a single episode of gross hematuria in a 42-year-old male should be a comprehensive urologic evaluation, including a detailed history and physical examination, urinalysis with microscopy, laboratory tests, upper tract imaging with a CT urogram, and cystoscopy to rule out underlying conditions such as urinary tract infection, kidney stones, bladder cancer, kidney cancer, and benign prostatic hyperplasia 1.
Causes of Gross Hematuria
The causes of gross hematuria can be divided into nephrogenic and urogenic causes. Nephrogenic causes include renal parenchymal disease, while urogenic causes include urolithiasis, infection, and benign prostatic hypertrophy 1. Malignant causes can occur anywhere in the urinary tract and must be excluded during the imaging evaluation of hematuria.
Evaluation Approach
The evaluation approach for gross hematuria should include:
- A detailed history and physical examination to identify risk factors and associated symptoms
- Urinalysis with microscopy to confirm the presence of red blood cells and assess for associated findings like proteinuria or pyuria
- Laboratory tests, including complete blood count, comprehensive metabolic panel, and coagulation studies
- Upper tract imaging with a CT urogram to detect urinary tract stones, renal masses, and urothelial lesions
- Cystoscopy to directly visualize the bladder and urethra and rule out bladder cancer or other lesions
Risk Factors and Urgency of Evaluation
The urgency of evaluation depends on associated symptoms and risk factors. Patients with risk factors like smoking history, occupational chemical exposure, or persistent bleeding should undergo more urgent evaluation 1. Complete evaluation is necessary even after a single episode resolves, as hematuria can be the first sign of serious underlying pathology.
Common Causes of Gross Hematuria
In a 42-year-old male, common causes of gross hematuria include:
- Urinary tract infection
- Kidney stones
- Bladder cancer
- Kidney cancer
- Benign prostatic hyperplasia
It is essential to note that gross hematuria has a high association with malignancy, and therefore, all patients with gross hematuria should have a full urologic workup 1.
From the Research
Causes of Gross Hematuria
The causes of gross hematuria in a 42-year-old male can be varied, including:
- Calculus (kidney stones) 2
- Trauma 2
- Tumors 3, 2
- Vascular causes, such as nutcracker syndrome 4
- Miscellaneous causes, including eosinophilic cystitis 5 and acquired hemophilia A 6
- Infections, such as urinary tract infections 3
- Benign prostatic hyperplasia 3
Diagnostic Approaches
Diagnostic approaches for gross hematuria include:
- Plain X-rays of the kidney, ureter, and bladder 2
- Ultrasound 2
- Intravenous urography 2
- Computed tomography (CT) scans, including CT urography 2, 4
- Magnetic resonance imaging 2
- Retrograde ureterography and pyelography (RGP) 2
- Cystoscopy 5, 4
- Ureteroscopy 2
Risk of Malignancy
The risk of malignancy with gross hematuria is greater than 10%, and prompt urologic referral is recommended 3