What is the appropriate management for a 23-year-old patient presenting with hematuria (blood in urine)?

Management of Hematuria in a 23-Year-Old Patient

A 23-year-old patient presenting with gross hematuria requires immediate urinalysis with microscopic examination, initial laboratory workup, and urgent urology referral regardless of other factors, as this is considered a high-risk presentation. 1

Initial Assessment and Diagnostic Evaluation

1. Confirm hematuria and assess severity:

   • Perform urinalysis with microscopic examination to:
     • Confirm presence of blood
     • Assess RBC morphology (dysmorphic vs. isomorphic)
     • Check for casts, crystals, pyuria, and proteinuria 1

2. Initial laboratory workup:

   • Complete urinalysis
   • Complete metabolic panel (including serum creatinine and BUN)
   • Urine culture
   • Urine cytology 1

3. Risk assessment:

   • Although this patient is young (23 years), gross hematuria carries >10% risk of malignancy and requires thorough evaluation 1, 2
   • Assess for other risk factors:
     • Smoking history
     • Occupational exposure to chemicals or dyes
     • Previous urologic disorders
     • Family history of renal disease 1

Imaging

For a young patient with gross hematuria, the appropriate imaging approach is:

• First-line imaging: Renal ultrasound (preferred in young patients due to lower radiation exposure) 1
• If trauma is suspected: Immediate CT urography 1, 3
• If renal insufficiency or contrast allergy: MR urography 1

Specialist Referral

• Mandatory urology referral for all cases of gross hematuria 1, 2
• Consider concurrent nephrology referral if:
  • eGFR <60 ml/min/1.73m²
  • Significant proteinuria
  • Dysmorphic RBCs or red cell casts are present 1

Management Considerations

• If urinary tract infection is identified, appropriate antibiotic therapy should be initiated 2, 4
• If urolithiasis is diagnosed, appropriate pain management and follow-up should be arranged 2
• If initial evaluation is negative, continued surveillance is essential 1

Follow-up and Surveillance

Even with a negative initial evaluation:

• Schedule repeat urinalysis within 12 months
• Monitor at 6,12,24, and 36 months with:
  • Repeat urinalysis
  • Urine cytology
  • Blood pressure measurement 1

Important Caveats

• Do not dismiss gross hematuria in young patients: While microscopic hematuria in young patients often has benign causes, gross hematuria requires thorough evaluation regardless of age 1, 2
• Watch for persistent hematuria: Even after treatment of apparent causes (like UTI), persistent hematuria requires continued evaluation 1
• Immediate re-evaluation needed if new symptoms develop, gross hematuria recurs, or microscopic hematuria increases 1
• Avoid diagnostic delays: The risk of malignancy with gross hematuria exceeds 10%, making prompt evaluation crucial 1, 2