What is the appropriate evaluation and management for a 68-year-old female presenting with hematuria?

Evaluation and Management of Hematuria in a 68-Year-Old Female

For a 68-year-old female with hematuria, a complete diagnostic workup including urinalysis confirmation, risk stratification, CT urography, and cystoscopy is essential to rule out urologic malignancy, which carries significant mortality risk if diagnosis is delayed.

Initial Assessment and Risk Stratification

Confirmation of Hematuria

• Confirm microscopic hematuria with proper urinalysis showing ≥3 RBC/HPF on microscopic evaluation from at least two of three properly collected specimens 1
• For gross hematuria, visual confirmation is sufficient

Risk Assessment

According to the 2025 AUA/SUFU guidelines, risk stratification for this patient would be:

• Age >60 years: Places female patients in intermediate risk category
• Degree of hematuria: Determines risk level (3-10 RBC/HPF = low risk; 11-25 RBC/HPF = intermediate risk; >25 RBC/HPF = high risk)
• Smoking history: Critical factor (>30 pack-years = high risk) 2

Initial Laboratory Evaluation

• Complete urinalysis (check for pyuria, bacteriuria, crystals, casts)
• Complete metabolic panel (BUN, creatinine, electrolytes)
• Serum creatinine to assess kidney function
• Urine culture to rule out infection
• Urine cytology 1

Imaging Studies

CT Urography

• First-line imaging for this 68-year-old female due to high sensitivity (92%) and specificity (93%) for urinary tract pathology 1
• Provides comprehensive evaluation of kidneys, ureters, and bladder
• Can identify stones, masses, and other structural abnormalities

Alternative Imaging Options

• MR urography if patient has renal insufficiency or contrast allergy
• Renal ultrasound as an alternative but has lower sensitivity (50%) compared to CT urography 1

Specialist Referral

Urology Referral

• Mandatory for this patient due to:
  • Age >60 years (intermediate risk)
  • Especially urgent if gross hematuria is present (>10% risk of malignancy) 3
  • Delayed referral (>9 months) is associated with worse cancer-specific survival in patients with bladder cancer 2

Nephrology Referral

• Consider if evidence of renal dysfunction (eGFR <60 ml/min/1.73m²)
• Indicated if there is persistent significant proteinuria or elevated creatinine 1

Cystoscopic Evaluation

• Essential for complete evaluation in this 68-year-old female
• Recommended by the American Urological Association for intermediate to high-risk patients regardless of imaging findings 1
• Direct visualization of bladder and urethra to detect lesions that may be missed on imaging

Common Pitfalls to Avoid

1. Delayed referral: Women have substantially lower rates of urology referral (8-28% vs. 36-47% for men), leading to potential delays in diagnosis 2

2. Attributing hematuria to UTI without evidence: Require supporting evidence of infection (pyuria, positive culture) before assuming UTI as the cause 1

3. Attributing hematuria to anticoagulant therapy: Patients on anticoagulants still require complete evaluation 1

4. Incomplete evaluation: Failure to perform both imaging and cystoscopy in high-risk patients can miss significant pathology

5. Ignoring clinical changes: New symptoms, gross hematuria, or increased degree of microscopic hematuria should prompt immediate re-evaluation 1

Follow-up

• If initial evaluation is negative but microscopic hematuria persists, repeat urinalysis within 12 months
• For patients with negative evaluations but persistent risk factors, consider annual surveillance
• Any development of gross hematuria or worsening microscopic hematuria requires prompt re-evaluation 1

Special Considerations for Female Patients

• Women have historically been under-referred for urologic evaluation despite hematuria 2
• Consider gynecologic causes of hematuria in female patients
• The 2025 AUA/SUFU guidelines recognize lower risk of urothelial malignancy in women, but age >60 still places them in intermediate risk category 2