From the Guidelines
The workup for hematuria should begin with a thorough history and physical examination, followed by urinalysis with microscopy to confirm the presence of red blood cells, and further evaluation is necessary for microscopic hematuria (>3 RBCs/HPF on two separate urinalyses) or any gross hematuria. For patients with hematuria, initial laboratory tests should include complete blood count, comprehensive metabolic panel, and urine culture to rule out infection 1. Imaging studies are essential, with CT urography being the preferred modality as it can detect urinary tract stones, renal masses, and urothelial lesions 1. Ultrasound with retrograde pyelography is an alternative for patients who cannot undergo CT.
Key Considerations
- Cystoscopy is recommended for all patients over 35 years with microscopic hematuria and for all patients with gross hematuria to evaluate the bladder and urethra for tumors or other abnormalities 1.
- For younger patients with risk factors such as smoking history, occupational exposures, or irritative voiding symptoms, cystoscopy should still be considered 1.
- If initial evaluation is negative but hematuria persists, follow-up evaluation in 6-12 months is recommended.
Evaluation Approach
The evaluation approach should be based on the patient's risk factors and the presence of gross or microscopic hematuria.
- Patients with gross hematuria should undergo a full urologic workup, given the high association with malignancy 1.
- Patients with microscopic hematuria should undergo a thorough history, physical examination, urinalysis, and serologic testing prior to any initial imaging 1.
- The use of CT urography as the preferred imaging modality is supported by its high sensitivity and specificity for detecting lesions of the renal parenchyma and the upper tracts 1.
Patient Factors
Patient factors, such as age, sex, and presence of risk factors, should be taken into consideration when evaluating hematuria.
- Older patients and those with risk factors, such as smoking history or occupational exposures, are at higher risk for significant urologic disease and should be considered for full urologic evaluation 1.
- The prevalence of asymptomatic microscopic hematuria varies by age and sex, and differences in the amount of follow-up and the number of screening studies per patient can account for the range of prevalence rates 1.
From the Research
Diagnostic Approach
The workup for hematuria typically begins with a thorough history and physical examination to determine potential causes and assess risk factors for malignancy 2. The evaluation of hematuria often requires various diagnostic procedures, but noninvasive techniques such as history, urinalysis, laboratory data, and ultrasonography should be used first to differentiate between renal and non-renal causes of hematuria 3.
Imaging Tests
- CT urography is recommended as the initial imaging test for hematuria in patients at high-risk for upper urinary tract urothelial cell carcinoma (UUT-UCC) due to its high diagnostic accuracy for UCC and favorable comparison with other imaging techniques 4.
- Ultrasonography can be used as an initial imaging test to evaluate the kidneys and bladder, but it may not provide sufficient information to rule out UUT-UCC or other serious conditions.
- Intravenous urography and retrograde ureteropyelography may be used in certain cases, but CT urography is generally preferred due to its higher diagnostic accuracy.
Laboratory Tests
- Urine culture and laboratory data should be obtained to rule out intrinsic renal disease and other benign causes of hematuria 5.
- Further laboratory tests may be ordered based on the results of the initial evaluation and the patient's risk factors for malignancy.