What is the appropriate workup for an 80-year-old patient presenting with hematuria (blood in urine)?

Evaluation of Hematuria in an 80-Year-Old Patient

For an 80-year-old patient with blood in the urine, a complete urologic evaluation is necessary, including urinalysis, upper tract imaging with CT urography, and cystoscopy, as this age group has a high risk of urologic malignancy. 1

Initial Assessment

• Determine if hematuria is gross (visible) or microscopic (≥3 red blood cells per high-power field on microscopic evaluation) 1
• Gross hematuria carries a higher risk of malignancy (30-40%) compared to microscopic hematuria (2.6-4%) 2, 3
• Exclude benign causes including infection, vigorous exercise, trauma, and medications 1, 4
• Obtain a clean-catch urine specimen; consider catheterization if clean-catch cannot be reliably obtained 1

Laboratory Evaluation

• Complete urinalysis with microscopic examination to assess:
  • Number of red blood cells per high-power field 1
  • Presence of dysmorphic red blood cells or red cell casts (suggesting glomerular origin) 1, 4
  • Presence of white blood cells or bacteria (suggesting infection) 1
• Urine culture to rule out urinary tract infection 1
• Measure serum creatinine to assess renal function 1, 4
• Urine cytology is recommended in all patients with hematuria at age 80 due to high risk for transitional cell carcinoma 1

Diagnostic Algorithm

Step 1: Determine if glomerular or non-glomerular source

• Glomerular source likely if:

  • Significant proteinuria (>500 mg/24 hours)
  • Dysmorphic RBCs (>80% dysmorphic)
  • Red cell casts
  • Elevated serum creatinine 1, 4

• Non-glomerular (urologic) source likely if:

  • Normal-shaped RBCs (>80% normal)
  • Minimal or no proteinuria
  • Normal serum creatinine 1, 4

Step 2: Management based on source determination

For Glomerular Source:

• Refer to nephrology for evaluation of systemic diseases and consideration of renal biopsy 1, 4

For Non-Glomerular Source (most likely in an 80-year-old):

• Complete urologic evaluation including:
  • Upper tract imaging
  • Cystoscopic examination 1

Imaging Recommendations

• CT urography is the preferred imaging modality for comprehensive evaluation of the upper urinary tract in an 80-year-old with hematuria 1, 5
• If CT is contraindicated (renal insufficiency or contrast allergy):
  • MR urography is an alternative 1, 5
  • Renal ultrasound with retrograde pyelography can be considered 1

Specialist Referral

• Urologic referral is indicated for:
  • All patients with gross hematuria
  • Patients with microscopic hematuria at age 80 (high-risk age group)
  • Patients with risk factors including smoking history or occupational exposures 1, 5
• Nephrology referral if evidence of glomerular disease (proteinuria >1,000 mg/24 hours, red cell casts, predominantly dysmorphic RBCs) 1, 4

Follow-up Recommendations

• For patients with negative initial evaluation:
  • Repeat urinalysis at 6,12,24, and 36 months
  • Monitor blood pressure
  • Consider nephrology referral if hematuria persists with development of hypertension, proteinuria, or evidence of glomerular bleeding 1, 5

Common Pitfalls to Avoid

• Do not attribute hematuria solely to benign prostatic hyperplasia without proper evaluation 5, 3
• Do not assume anticoagulation therapy is the cause of hematuria without thorough evaluation 5
• Do not omit cystoscopy in elderly patients with hematuria, as the risk of malignancy increases with age 1, 6
• Do not delay evaluation of gross hematuria, as it carries a higher risk of malignancy 3, 6