What is the appropriate management for a 36-year-old woman presenting with gross hematuria?

Management of Gross Hematuria in a 36-Year-Old Woman

A 36-year-old woman presenting with gross hematuria requires urgent urologic referral for complete evaluation including cystoscopy and upper tract imaging, as gross hematuria carries a high risk of underlying malignancy (>10%) and should never be ignored even if self-limited. 1, 2

Initial Assessment

• Gross hematuria has a significantly higher association with malignancy (30-40%) compared to microscopic hematuria (2.6-4%), necessitating prompt and thorough evaluation 1
• All patients with gross hematuria warrant urologic referral, regardless of whether the bleeding is self-limited 1
• Antiplatelet or anticoagulant therapy is not considered a satisfactory explanation for hematuria and should not prevent full evaluation 1

Diagnostic Workup

Imaging

• Multiphase CT urography is the preferred imaging modality for evaluating the upper urinary tract in patients with hematuria 1
• CT urography should include:
  • Unenhanced images
  • IV contrast-enhanced images with nephrographic and excretory phases
  • Thin-slice acquisition 1
• Alternative imaging options if CT is contraindicated:
  • Ultrasonography (though less sensitive than CT urography) 1
  • MR urography for patients with contrast allergies or renal insufficiency 3

Cystoscopy

• Complete visualization of the bladder mucosa, urethra, and ureteral orifices is necessary to exclude bladder cancer 1
• Flexible cystoscopy is preferred as it:
  • Causes less pain than rigid cystoscopy
  • Has fewer post-procedure symptoms
  • Requires simpler positioning and preparation
  • Takes less time to perform 1

Laboratory Testing

• Urinalysis with microscopic confirmation of hematuria
• Serum creatinine to assess renal function 1
• Urine culture to rule out infection as a cause 1
• Urine cytology is no longer routinely recommended in the initial evaluation 1
• FDA-approved urine markers for bladder cancer detection (NMP22, BTA stat, ImmunoCyt, UroVysion FISH) are not recommended for initial evaluation 1

Special Considerations

• Women with hematuria often experience longer delays in referral to urology compared to men (despite women presenting with more advanced disease and having higher case-fatality rates when diagnosed with bladder cancer) 1
• Common causes of gross hematuria include:
  • Urinary tract malignancy (bladder, kidney, ureter)
  • Urolithiasis
  • Urinary tract infection
  • Benign prostatic hyperplasia (in men) 2, 3

Follow-up

• Even if initial evaluation is negative, patients with a history of gross hematuria require follow-up due to the intermittent nature of bleeding from urologic malignancies 1
• Follow-up should include:
  • Repeat urinalysis
  • Blood pressure monitoring
  • Consideration for repeat imaging and cystoscopy if hematuria persists 1
• Immediate urologic reevaluation is warranted if gross hematuria recurs, urinary cytology becomes abnormal, or irritative voiding symptoms develop in the absence of infection 1

Common Pitfalls to Avoid

• Dismissing gross hematuria as self-limited without proper evaluation 1
• Failing to refer patients with gross hematuria for urologic evaluation (studies show 23-36% of primary care physicians do not routinely refer these patients) 1
• Attributing hematuria to anticoagulant or antiplatelet therapy without further investigation 1
• Neglecting to specifically ask patients about prior episodes of visible blood in the urine, as self-limited gross hematuria is often underreported but highly significant 1