What is the appropriate workup for a male patient presenting with hematuria?

Workup for Hematuria in Male Patients

The appropriate workup for a male patient presenting with hematuria should include risk stratification, urinalysis, serum PSA testing, appropriate imaging, and cystoscopy based on risk factors. 1

Initial Risk Assessment

Risk stratification is essential to guide the extent of evaluation:

Risk Factors for Urologic Malignancy

• Age >60 years
• Smoking history
• Exposure to industrial chemicals
• Family history of renal cell carcinoma or genetic renal tumor syndrome
• Degree of hematuria (gross hematuria carries highest risk)

Diagnostic Evaluation Algorithm

Step 1: Confirm Hematuria

• Urinalysis to confirm presence of red blood cells
• Determine if microscopic (≥3-5 RBCs/HPF) or gross hematuria
• Assess for pyuria, bacteriuria, crystals, and casts

Step 2: Basic Laboratory Tests

• Complete metabolic panel (BUN, creatinine, electrolytes)
• Serum PSA measurement in men with at least a 10-year life expectancy 2
• Urine culture to rule out infection

Step 3: Imaging Based on Risk

• Low-Risk Patients (age ≤40, <5 RBCs/HPF, no risk factors):

  • Renal ultrasound
  • Repeat urinalysis in 3 months

• Intermediate/High-Risk Patients (age >40, ≥5 RBCs/HPF, or risk factors present):

  • CT urography (92% sensitivity, 93% specificity) 1
  • Alternative options if CT contraindicated:
    • MR urography (renal insufficiency or contrast allergy)
    • Renal ultrasound (younger patients)

Step 4: Cystoscopy

• Recommended for all patients with:
  • Gross hematuria
  • Age >40 with microscopic hematuria
  • Risk factors for urologic malignancy
  • Persistent unexplained hematuria

Step 5: Additional Testing Based on Clinical Suspicion

• Urine cytology for patients with:
  • Irritative voiding symptoms
  • Risk factors for carcinoma in situ 1
• Consider prostate biopsy if prostate cancer is suspected 2

Special Considerations

Benign Prostatic Hyperplasia (BPH)

• Common cause of hematuria in older men
• Digital rectal examination to assess prostate size
• Consider PSA testing as it may predict natural history of BPH 2

Acute Management

• For patients with gross hematuria and clots:
  • Consider continuous bladder irrigation
  • Monitor for urinary retention 3

Follow-up Recommendations

• Patients with negative initial evaluation should have repeat urinalysis within 12 months
• Persistent microscopic hematuria requires continued surveillance
• Consider nephrology referral if there is:
  • Significant proteinuria
  • Elevated creatinine
  • eGFR <60 ml/min/1.73m² 1

Common Pitfalls to Avoid

1. Do not attribute hematuria to anticoagulant therapy without proper evaluation - these patients still require complete workup 1

2. Do not assume hematuria is due to UTI without supporting evidence of infection (pyuria, positive culture) 1

3. Do not ignore clinical changes such as new symptoms, gross hematuria, or increased degree of microscopic hematuria, as these should prompt immediate re-evaluation 1

4. Do not delay urologic referral for patients with gross hematuria, as the risk of malignancy exceeds 10% 4

5. Do not forget to consider non-urological causes of hematuria, including nephropathies, which may require nephrology consultation 5

By following this structured approach, clinicians can ensure appropriate evaluation of male patients presenting with hematuria, focusing on identifying potentially serious underlying conditions while avoiding unnecessary testing in low-risk individuals.