Management of Blood in Urine (Hematuria)
If you have blood in your urine, you should seek prompt medical evaluation as this may indicate a serious underlying condition requiring timely diagnosis and treatment. 1
Initial Assessment and Risk Stratification
Blood in urine (hematuria) can be categorized as:
- Macroscopic/gross hematuria: Visible blood in urine (appears red, pink, or cola-colored)
- Microscopic hematuria: Blood detected only through laboratory testing
Risk Factors for Urologic Malignancy 1
- Age (women ≥50 years, men ≥40 years)
- Smoking history (>30 pack-years)
- Intensity of hematuria (>25 RBC/HPF or macroscopic hematuria)
- History of pelvic radiation
- Chronic urinary infections
- Irritative voiding symptoms
- Occupational exposures to chemicals or dyes
- Family history of renal cell carcinoma
Recommended Diagnostic Pathway
Step 1: Confirm Hematuria and Rule Out Benign Causes
- Repeat urinalysis to confirm persistence of hematuria
- Urine culture to rule out infection
- Complete blood count, urea, creatinine tests
- Evaluation of proteinuria (>300 mg/dL requires nephrology referral) 1
Step 2: Imaging Based on Risk Category
| Risk Level | Recommended Imaging |
|---|---|
| High-risk (older age, smoking history, gross hematuria) | CT urography |
| Renal insufficiency or contrast allergy | MR urography or ultrasound |
| Young patients with lower risk | Renal ultrasound |
Step 3: Specialist Referral
Urologic referral is required for:
- All cases of gross/macroscopic hematuria (>10% risk of malignancy) 2
- Persistent microscopic hematuria with no benign cause identified
- High-risk patients based on risk factors
Nephrology referral is required for:
- Significant proteinuria (>1g/day)
- Signs of glomerular disease
- Abnormal renal function tests 1
Common Pitfalls to Avoid
Delayed evaluation: Delays >9 months in evaluating hematuria in patients with bladder cancer are associated with decreased survival 1
Inadequate imaging: Using only ultrasound in high-risk patients may miss significant pathology 1
Sex disparities: Women with hematuria are often referred less frequently but tend to have more advanced disease when diagnosed 1
Assuming benign cause: Never assume a benign cause without complete evaluation in high-risk patients 1
Dismissing microscopic hematuria: Even microscopic hematuria warrants thorough evaluation, especially with risk factors 1
Follow-up Recommendations
Immediate reevaluation if:
- Macroscopic hematuria appears
- Significant increase in microscopic hematuria
- New urological symptoms develop 1
For persistent microscopic hematuria:
- Repeat urinalysis within 2 weeks
- Monitor renal function, electrolytes, and urinalysis
- Maintain strict blood pressure control (target ≤125/75 mmHg) 1
Important Note
The risk of urologic malignancy with gross hematuria exceeds 10%, making prompt evaluation critical 2. Studies show that only 77% of primary care physicians refer patients with gross hematuria to urologists, and only 36% refer those with microscopic hematuria 3, potentially delaying diagnosis of serious conditions.