Diagnostic Workup for Hematuria in Males
The diagnostic workup for hematuria in males should follow a risk-stratified approach, with all males over 60 years, those with risk factors, or those with gross hematuria requiring comprehensive evaluation including cystoscopy and upper tract imaging. 1
Initial Assessment and Risk Stratification
Classification of Hematuria
- Gross hematuria (macroscopic): Visible blood in urine - highest risk for malignancy (>10%)
- Microscopic hematuria:
- ≥3 RBCs per high-power field on microscopic examination
- Further stratified by:
- <5 RBCs/HPF (lower risk)
- ≥5 RBCs/HPF (higher risk)
Risk Factors for Urologic Malignancy
- Age >60 years
- Male sex
- Smoking history
- Occupational exposure to chemicals or dyes (benzenes, aromatic amines)
- History of gross hematuria
- History of urologic disorder or disease
- History of pelvic irradiation
- Family history of renal cell carcinoma or urothelial carcinoma
- Chronic urinary tract infection
- Exposure to cyclophosphamide or aristolochic acid
Diagnostic Algorithm
Step 1: Initial Laboratory Evaluation
- Urinalysis with microscopy to confirm hematuria and assess for:
- Pyuria, bacteriuria (suggesting infection)
- RBC morphology (dysmorphic RBCs suggest glomerular source)
- Proteinuria (suggesting renal disease)
- Crystals or casts
- Urine culture to rule out infection
- Complete metabolic panel (BUN, creatinine, electrolytes)
- Complete blood count
- Serum PSA in men over 40 years
Step 2: Risk-Based Evaluation
Low-Risk Patients
Age ≤40 years, <5 RBCs/HPF, no risk factors
- Repeat urinalysis in 3 months
- If resolved: No further workup needed
- If persistent: Consider renal ultrasound
Intermediate/High-Risk Patients
Age >40 years, ≥5 RBCs/HPF, or risk factors present
- Upper Tract Imaging (one of the following):
- CT urography (preferred for most patients)
- MR urography (for patients with renal insufficiency or contrast allergy)
- Renal ultrasound (for younger patients or as initial screening)
- Cystoscopy (essential for all high-risk patients)
- The American Urological Association recommends cystoscopy for all patients with persistent microscopic hematuria after negative initial evaluation 2
- Urine Cytology for patients with:
- Irritative voiding symptoms
- Risk factors for carcinoma in situ
- History of smoking
Step 3: Additional Evaluation Based on Findings
For Suspected Glomerular Source
Dysmorphic RBCs, proteinuria, casts, or elevated creatinine
- Urine protein quantification
- Serum albumin and total protein
- Consider nephrology referral if:
- Significant proteinuria
- Elevated creatinine or BUN
- eGFR <60 ml/min/1.73m²
For Suspected Urologic Source
Normal-shaped RBCs, no proteinuria, normal renal function
- Complete urologic evaluation as outlined above
- Urology referral for:
- Gross hematuria
- Abnormal genitourinary anatomy
- Suspected stones or tumors
- Persistent microscopic hematuria without proteinuria
Follow-Up Recommendations
After Negative Initial Evaluation
- For persistent asymptomatic microhematuria after negative urologic workup, yearly urinalyses should be conducted 2
- Consider repeat evaluation within 3-5 years for persistent or recurrent asymptomatic microhematuria 2
Special Considerations
- Changes in clinical scenario (increased hematuria, new symptoms) warrant earlier re-evaluation
- Patients with persistent hematuria attributed to benign conditions (e.g., enlarged prostate with friable vessels) should still undergo annual urinalysis 2
Common Pitfalls to Avoid
- Ignoring hematuria in patients on anticoagulants - These patients still require complete workup
- Attributing hematuria solely to UTI without supporting evidence - Confirm resolution after treatment
- Inadequate follow-up - The overwhelming majority of patients with thorough negative initial workup remain cancer-free, but a small proportion may develop disease over time 2
- Failure to recognize glomerular sources - Dysmorphic RBCs with proteinuria require nephrology evaluation rather than urologic workup
By following this risk-stratified approach, clinicians can ensure appropriate evaluation of hematuria in male patients while avoiding unnecessary testing in low-risk individuals.