What is the evaluation and management of gross hematuria?

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

Initial Assessment

• Confirm true hematuria with microscopic examination (≥3 red blood cells per high-power field) rather than relying solely on dipstick results 2
• Assess for potential benign causes including:
  • Urinary tract infection (obtain urine culture) 2
  • Vigorous exercise or trauma 1
  • Medications that may cause hematuria 1
• Obtain a clean-catch urine specimen, considering catheterization if necessary 1
• Do not attribute hematuria solely to antiplatelet or anticoagulant therapy without further investigation 1, 2

Laboratory Evaluation

• Complete urinalysis with microscopic examination to assess:
  • Number of red blood cells per high-power field
  • Presence of dysmorphic red blood cells or red cell casts (suggesting glomerular source)
  • Presence of white blood cells or bacteria (suggesting infection) 1
• Urine culture to rule out urinary tract infection 1
• Serum creatinine to assess renal function 1, 2
• Urine cytology in all patients with hematuria, especially elderly patients due to high risk for transitional cell carcinoma 1

Diagnostic Algorithm

Determining Source of Bleeding

• Glomerular source likely if:

  • Significant proteinuria (>500 mg/24 hours)
  • Dysmorphic RBCs (>80%)
  • Red cell casts
  • Elevated serum creatinine 1, 2

• Non-glomerular (urologic) source likely if:

  • Normal-shaped RBCs
  • Minimal or no proteinuria
  • Normal serum creatinine 1

Imaging Recommendations

• CT urography is the preferred imaging modality for comprehensive evaluation of the upper urinary tract 1
• MR urography is an alternative if CT is contraindicated 1
• Renal ultrasound with retrograde pyelography can be considered if CT and MR are not feasible 1

Specialist Referral

• Urgent urologic referral is mandatory for all patients with gross hematuria, even if self-limited 1, 2, 3
• Nephrology referral is recommended if there is evidence of glomerular disease (proteinuria, red cell casts, or predominantly dysmorphic RBCs) 1, 2

Risk Factors for Urologic Malignancy

• Age >40 years 2
• Smoking history 2
• Occupational exposure to chemicals or dyes (benzenes or aromatic amines) 2
• Irritative voiding symptoms 2
• History of pelvic irradiation 2

Follow-up Recommendations

• For patients with negative initial evaluation, repeat urinalysis at 6,12,24, and 36 months 1, 2
• Monitor blood pressure and consider nephrology referral if hematuria persists with development of hypertension, proteinuria, or evidence of glomerular bleeding 1, 2
• Immediate urologic reevaluation is necessary if any of the following occur:
  • Recurrent gross hematuria
  • Abnormal urinary cytology
  • Irritative voiding symptoms in the absence of infection 1

Common Pitfalls to Avoid

• Do not delay evaluation even if hematuria resolves spontaneously 1
• Do not assume hematuria is due to antiplatelet or anticoagulant medications if the patient is taking them 1
• Do not delay urologic referral while waiting for other test results in a patient with gross hematuria 1
• Do not underestimate the significance of gross hematuria - risk of malignancy is greater than 10% 3
• Do not rely solely on urine dipstick testing without microscopic confirmation 2