What's the next step in managing a 68-year-old patient with microscopic hematuria (blood in urine), negative urine culture, and incidental findings on CT scans, including a hiatal hernia, obstipation of the colon, and a degenerative fibroid?

Management of Microscopic Hematuria in a 68-Year-Old Patient with Negative CT Findings

The next step in managing this 68-year-old patient with microscopic hematuria should be cystoscopy to evaluate the lower urinary tract, despite negative CT findings. 1

Risk Assessment and Rationale

This patient falls into a high-risk category for urologic malignancy based on:

• Age (68 years, with ≥40 years in men being a risk factor)
• Presence of microscopic hematuria with negative culture

While the CT scan shows no abnormalities of the kidneys, upper tracts, lower tracts, or bladder, this does not completely rule out significant pathology. Up to 5% of patients with asymptomatic microscopic hematuria may have urinary tract malignancy 2, and delays in evaluation can impact survival outcomes 1.

Recommended Diagnostic Algorithm

1. Cystoscopy with white light examination

   • Essential for evaluating the lower urinary tract, including the bladder and urethra
   • Can detect lesions that may be missed on CT imaging
   • Particularly important in high-risk patients (age ≥40 in men) 1, 2

2. Urine cytology consideration

   • While no longer routinely recommended for all cases of microscopic hematuria 2
   • Consider in this high-risk patient if cystoscopy is negative

3. Laboratory evaluation

   • Complete blood count, renal function tests (BUN, creatinine)
   • Urinalysis to quantify proteinuria
   • If proteinuria >300 mg/dL, nephrology referral is indicated 1

4. Address incidental findings

   • Hiatal hernia: Document and refer for GI evaluation if symptomatic
   • Obstipation of the colon: Recommend increased fiber intake, hydration, and consider stool softeners
   • Degenerative fibroid: No specific intervention required for this incidental finding

Follow-up Plan

• If initial evaluation is negative, repeat urinalysis in 3-6 months to confirm resolution or persistence of hematuria
• Immediate reevaluation if gross hematuria develops, microscopic hematuria worsens, or new urological symptoms appear 1
• Consider nephrological consultation if there are signs of glomerular disease (dysmorphic RBCs, proteinuria, elevated creatinine)

Important Considerations and Pitfalls

• Do not assume benign cause without complete evaluation: A common pitfall is assuming microscopic hematuria has a benign cause without thorough evaluation, especially in high-risk patients 1

• CT limitations: While CT urography has high sensitivity (92%) and specificity (93%) for many urinary tract abnormalities, small bladder lesions may be missed 1

• Avoid sex disparities: Ensure equal thoroughness in evaluation regardless of patient sex 1

• Recognize that "normal" imaging does not exclude pathology: Up to 5% of patients with microscopic hematuria and normal imaging may still have significant urological disease 2

• Consider functional causes: If structural evaluation is negative, consider functional studies to evaluate for non-obstructive causes of hematuria 1