Evaluation and Management of Gross Hematuria
All patients with gross hematuria require urgent urologic referral for cystoscopy and imaging due to the high risk of underlying malignancy (>10%), even if the bleeding is self-limited. 1, 2, 3
Initial Assessment
- Gross hematuria carries a significantly higher risk of malignancy (30-40%) compared to microscopic hematuria (2.6-4%) and requires immediate attention 2
- Painless gross hematuria has a stronger association with cancer than hematuria accompanied by flank pain, which may suggest urinary stone disease 1
- Include questions about gross hematuria in routine review of systems as visible blood in urine is often underreported but significantly increases cancer risk (odds ratio 7.2) 3
- Do not attribute hematuria solely to antiplatelet or anticoagulant therapy without further investigation 1, 2
Diagnostic Approach
Laboratory Evaluation
- Complete urinalysis with microscopic examination to assess the number of red blood cells per high-power field, presence of dysmorphic red blood cells or red cell casts 2
- Urine culture to rule out urinary tract infection 2
- Serum creatinine to assess renal function 2
- Urine cytology may be considered in high-risk patients, though the American College of Physicians does not recommend urine cytology or other urine-based molecular markers for bladder cancer detection in the initial evaluation 1, 2
Imaging Studies
- CT urography (CT abdomen/pelvis with IV contrast) is the preferred imaging modality for comprehensive evaluation of the urinary tract in patients with hematuria 2
- MR urography is an alternative if CT is contraindicated 2
- Renal ultrasound with retrograde pyelography can be considered if CT and MR are not feasible 2
Specialist Referral
- Urgent urologic referral is mandatory for all patients with gross hematuria, even if self-limited 1, 2
- The urologist will perform cystoscopy to exclude bladder cancer 2
- Nephrology referral is recommended if there is evidence of glomerular disease, such as proteinuria, red cell casts, or predominantly dysmorphic RBCs 2
Differential Diagnosis
- Urinary tract malignancy (bladder, kidney, ureter) 1, 4
- Urinary tract infection 4
- Urinary calculi 4
- Benign prostatic hyperplasia 4
- Cyst hemorrhage in conditions like polycystic kidney disease 5
- Trauma-related bleeding (consider in context of recent injury) 6
- Glomerular diseases 2
Common Pitfalls to Avoid
- Do not delay urologic referral while waiting for other test results in a patient with gross hematuria 2
- Do not assume hematuria is due to antiplatelet or anticoagulant medications if the patient is taking them 1, 2
- Do not delay evaluation even if hematuria resolves spontaneously 2
- Avoid attributing hematuria to benign causes without appropriate investigation, as studies show primary care physicians often underrefer patients with hematuria 7
Follow-up Recommendations
- For patients with negative initial evaluation, repeat urinalysis at 6,12,24, and 36 months 1, 3
- Monitor blood pressure and consider nephrology referral if hematuria persists with development of hypertension, proteinuria, or evidence of glomerular bleeding 1, 3
- Immediate urologic reevaluation is necessary if any of the following occur: recurrent gross hematuria, abnormal urinary cytology, or irritative voiding symptoms in the absence of infection 1