Recommended Review of Systems (ROS) for Hematuria
A comprehensive ROS for hematuria should specifically inquire about visible (gross) hematuria, even if self-limited, as this is strongly associated with urologic cancer (OR 7.2) and should be part of routine review of systems. 1
Essential ROS Components
Urinary System
- Duration and pattern of hematuria (intermittent vs. continuous)
- Timing of hematuria during urination (initial, terminal, or total)
- Color and appearance of urine (tea-colored, bright red, clots)
- Associated urinary symptoms:
- Dysuria, frequency, urgency
- Flank pain or costovertebral angle tenderness
- Suprapubic pain
- Incomplete emptying or straining to void
- Nocturia
Risk Factors for Urologic Malignancy
- Smoking history (current or former)
- Age >40 years (higher risk >60 years)
- Occupational exposure to chemicals or dyes
- Previous urologic disorders
- Family history of urologic malignancies 2
Systemic Symptoms
- Recent fever, weight loss, night sweats
- Fatigue or malaise
- Hypertension
- Edema (periorbital, lower extremity)
- Rashes or skin changes
- Joint pain or arthritis 1
Trauma History
- Recent trauma (even minor)
- Exercise-induced hematuria
- Foreign body insertion
- Sexual abuse (particularly in children) 1
Medication History
- Anticoagulant use
- NSAIDs or aspirin use
- Medications that may discolor urine (rifampin, phenazopyridine) 2
Family History
- Renal stones
- Polycystic kidney disease
- Sickle cell disease or trait
- Hemophilia or other bleeding disorders
- Alport syndrome (inquire about hearing loss in family) 1
Special Considerations
For Children
- Growth parameters (height and weight)
- Recent infections
- Hearing status (for Alport syndrome)
- Rashes (Henoch-Schönlein purpura)
- Edema (nephrotic syndrome)
- Family history of renal disease 1
For Adults with Risk Factors
- Prior urologic procedures
- History of recurrent UTIs
- Radiation exposure
- Chronic analgesic use
- Chronic catheterization 2
Clinical Pearls and Pitfalls
Critical insight: A history of self-limited gross hematuria is significantly underreported but carries a high risk for urologic cancer. Always specifically ask about any episodes of visible blood in urine, even if resolved. 1
Common pitfall: Failing to recognize that gross hematuria, even if self-limited, requires urgent evaluation due to >10% risk of malignancy. 2, 3
Important distinction: Tea-colored urine with proteinuria, RBC casts, and deformed RBCs suggests glomerular source, while bright red blood with clots suggests lower urinary tract source. 1
Risk stratification: Patients with risk factors (age >60, smoking history, occupational exposures) require more thorough evaluation even with microscopic hematuria. 2
By systematically covering these areas in the ROS, clinicians can better direct subsequent diagnostic workup and determine appropriate referrals to urology or nephrology based on the suspected etiology of hematuria.