From the Guidelines
Painless hematuria is most commonly caused by urinary tract cancers, such as bladder cancer, and requires prompt medical evaluation to rule out malignancy. The initial approach should include a thorough history, physical examination, urinalysis, and urine culture. For adults over 35, cystoscopy and upper tract imaging (CT urography) are recommended to rule out malignancy 1. Common causes of painless hematuria include:
- Urinary tract infections
- Kidney stones
- Benign prostatic hyperplasia
- Kidney disease
- Urinary tract cancers, such as bladder cancer Treatment depends on the underlying cause, and may include:
- Antibiotics for infections (such as nitrofurantoin 100mg twice daily for 5-7 days for uncomplicated UTIs)
- Alpha-blockers for BPH (tamsulosin 0.4mg daily)
- Specific interventions for stones or tumors Patients should increase fluid intake to 2-3 liters daily during evaluation. The urgency of evaluation increases with risk factors like age over 35, smoking history, chemical exposures, or prior urologic disorders. Painless hematuria should never be ignored, as early detection of conditions like bladder cancer significantly improves outcomes through earlier intervention 1.
Key Considerations
- Cystoscopy is a crucial diagnostic tool for detecting bladder cancer in patients with hematuria 1
- Upper tract imaging (CT urography) is recommended to screen for synchronous upper urinary tract urothelial carcinoma (UTUC) in cases of high-grade bladder cancer 1
- The diagnostic accuracy of cystoscopy for detecting bladder cancer in adults presenting with hematuria is an important consideration in clinical practice 1
From the Research
Causes of Painless Hematuria
The causes of painless hematuria can be varied and may include:
- Urinary tract infection
- Urolithiasis (urinary tract stones)
- Bladder cancer
- Upper urinary tract urothelial cell carcinoma (UUT-UCC)
- Renal cell cancer
- Glomerular disease 2, 3, 4
- Urothelial cancer 5, 4, 6
Diagnostic Evaluation
The diagnostic evaluation of painless hematuria may involve:
- Urine microscopy to detect erythrocytes
- Measurement of inflammatory parameters and renal function tests
- Ultrasonography of the kidneys and bladder
- Cystoscopy and immunocytology for patients with risk factors such as smoking, advanced age, and male sex 2, 5
- CT urography for patients at high-risk for urothelial cell carcinoma (UCC) 4
- Intravenous pyelography or sonography as the first procedure performed 3
Risk Factors
Certain risk factors may increase the likelihood of underlying conditions, including: