What is the management approach for a patient presenting with gross hematuria?

Management of Gross Hematuria

Gross hematuria requires prompt and thorough evaluation as it carries a >10% risk of malignancy and should always trigger immediate urologic referral for complete investigation. 1, 2

Initial Evaluation

1. Risk Stratification:

   • High-risk factors include:
     • Age (women ≥50 years, men ≥40 years)
     • Smoking history >30 pack-years
     • History of pelvic radiation
     • Chronic urinary infections
     • Occupational exposures to dyes or chemicals 1

2. Laboratory Assessment:

   • Urinalysis confirmation of hematuria
   • Urine culture to rule out infection
   • Complete blood count
   • Renal function tests (BUN, creatinine)
   • Evaluation for proteinuria (>300 mg/dL requires nephrology referral) 1
   • Urine cytology (particularly with irritative voiding symptoms) 1

Diagnostic Imaging

• First-line imaging: CT urography (92% sensitivity, 93% specificity) 1
• Alternative imaging (for patients with renal insufficiency or contrast allergy):
  • MR urography
  • Renal ultrasound (50% sensitivity, 95% specificity) 1

Specialist Referral

• Immediate urology referral for cystoscopy in all cases of gross hematuria 1, 2
• Nephrology referral if:
  • Significant proteinuria (>1g/day)
  • Evidence of glomerular disease
  • Renal insufficiency 1

Specific Management Based on Etiology

1. Urinary Tract Infection:

   • Appropriate antibiotic therapy based on culture results 1

2. Urolithiasis:

   • Pain management
   • Hydration
   • Urologic intervention for obstructing stones 1

3. Benign Prostatic Hyperplasia:

   • Medical therapy or surgical intervention as indicated 1

4. Malignancy:

   • Prompt referral for definitive management
   • Delays >9 months in evaluation are associated with decreased survival in bladder cancer 1

5. Anticoagulant-Associated Bleeding:

   • Full urologic evaluation is still warranted even with excessive anticoagulation
   • Tumors were found in 18% of patients with excessive anticoagulation 3

Follow-up and Monitoring

• Repeat urinalysis within 2 weeks to assess persistence 1
• Close monitoring of renal function and electrolytes 1
• Immediate reevaluation if:
  • Recurrence of gross hematuria
  • Significant increase in microscopic hematuria
  • Development of new urological symptoms 1

Common Pitfalls to Avoid

• Assuming a benign cause without complete evaluation, especially in high-risk patients 1
• Using inadequate imaging (e.g., ultrasound alone) in high-risk patients 1
• Dismissing hematuria in patients with overactive bladder symptoms 1
• Sex-based disparities in referral patterns 1
• Delaying evaluation (>9 months) which can decrease survival in patients with bladder cancer 1
• Deferring investigation due to anticoagulant use - even patients with excessive anticoagulation require full evaluation 3

Remember that gross hematuria represents a serious finding that warrants immediate and thorough investigation. The physician who delays or defers careful investigation does the patient a disservice and may inadvertently permit a significant disease process to become more extensive 4.