What is the typical workup for a patient with acute onset of hematuria?

Workup for Acute Onset of Hematuria

The typical workup for a patient with acute onset of hematuria should include a thorough history and physical examination, urinalysis with microscopic confirmation, urine culture, serum creatinine measurement, risk stratification, and appropriate imaging and cystoscopy based on risk factors. 1, 2

Initial Evaluation

History and Physical Examination

• Obtain detailed history focusing on:
  • Age and sex (men ≥60 years and women ≥60 years are at higher risk) 1
  • Smoking history (pack-years categorized as <10-30, or >30) 1
  • History of gross hematuria
  • Family history of urologic malignancies
  • Occupational/environmental exposures
  • Medication use (especially anticoagulants)
  • Symptoms (dysuria, frequency, flank pain)
• Physical examination should include:
  • Blood pressure measurement
  • Abdominal examination
  • Genitourinary examination

Laboratory Testing

• Urinalysis with microscopic examination
  • Confirm hematuria with ≥3 RBC/HPF on 2 of 3 properly collected specimens 2
  • Assess for dysmorphic RBCs (suggesting glomerular source)
  • Check for proteinuria, pyuria, and casts
• Serum creatinine to assess renal function 1
• Urine culture to rule out infection 2

Risk Stratification

The AUA/SUFU 2025 guidelines recommend stratifying patients into three risk categories 1:

1. Low/Negligible Risk (0%-0.4% risk of malignancy)

   • 3-10 RBC/HPF
   • Women <60 years or men <40 years
   • Never smoker or <10 pack-years

2. Intermediate Risk (0.2%-3.1% risk of malignancy)

   • 11-25 RBC/HPF, OR
   • Women ≥60 years or men 40-59 years, OR
   • 10-30 pack-years smoking history

3. High Risk (1.3%-6.3% risk of malignancy)

   • 25 RBC/HPF, OR

   • Men ≥60 years, OR

   • 30 pack-years smoking history

Imaging and Further Evaluation

Based on Risk Category:

• Low/Negligible Risk:

  • Consider renal ultrasound 2
  • Follow-up urinalysis in 6-12 months

• Intermediate Risk:

  • CT urography (92% sensitivity, 93% specificity for urologic abnormalities) 2
  • Cystoscopy
  • Consider urine cytology

• High Risk:

  • CT urography
  • Cystoscopy
  • Urine cytology

Special Considerations:

• For patients with renal insufficiency or contrast allergy, consider MR urography or ultrasound 2
• Young patients may start with renal ultrasound (50% sensitivity, 95% specificity) 2
• Patients with gross hematuria should undergo complete evaluation regardless of other risk factors due to >10% risk of malignancy 3

Follow-up Management

• If initial evaluation is negative but hematuria persists:

  • Annual urinalysis for persistent asymptomatic microhematuria
  • If two consecutive negative annual urinalyses, no further evaluation needed
  • Consider repeat evaluation within 3-5 years for persistent/recurrent hematuria 2

• Nephrology referral indicated for:

  • Proteinuria >1,000 mg/24 hours
  • Evidence of glomerular disease (dysmorphic RBCs, RBC casts)
  • Declining renal function 2

Common Pitfalls to Avoid

1. Underestimating microscopic hematuria: Even microscopic hematuria can indicate serious underlying pathology and should not be dismissed without appropriate evaluation 2

2. Relying solely on imaging: Most cancers diagnosed in patients with hematuria are bladder cancers, optimally detected with cystoscopy, not just imaging 1

3. Incomplete risk stratification: Failing to consider all risk factors (age, smoking history, degree of hematuria) can lead to inadequate evaluation 1

4. Delayed evaluation: Delays in diagnosis of bladder cancer can contribute to a 34% increased risk of cancer-specific mortality 1

5. Stopping at benign findings: Even if a benign cause is identified (e.g., UTI), persistent hematuria after treatment warrants complete evaluation 2