What is the appropriate workup for hematuria (blood in urine)?

From the Guidelines

Hematuria workup should begin with a thorough history and physical examination, followed by urinalysis with microscopy to confirm the presence of red blood cells, as recommended by the most recent guidelines 1. The initial evaluation should include a complete blood count, serum creatinine, and urine culture.

• If microscopic hematuria is confirmed (>3 RBCs per high-power field), further evaluation is necessary, including imaging studies such as renal ultrasound or CT urography to assess the kidneys, ureters, and bladder.
• Cystoscopy is recommended for all patients over 35 years with microscopic hematuria and for any patient with gross hematuria to directly visualize the bladder and urethra, as suggested by the American College of Radiology 1.
• For patients with risk factors such as smoking history, occupational exposures, or age >50, more aggressive evaluation is warranted, as advised by the American College of Physicians 1.
• If initial workup is negative but hematuria persists, consider referral to nephrology to evaluate for glomerular causes, as recommended by the American Urological Association 1.
• Patients with gross hematuria, especially with clots, should be evaluated urgently, as they have a high association with malignancy, as noted in the Journal of the American College of Radiology 1. The comprehensive approach is necessary because hematuria can indicate serious underlying conditions, including malignancy, urolithiasis, infection, or glomerular disease, and early detection significantly improves outcomes, as emphasized by the Annals of Internal Medicine 1. Follow-up urinalysis should be performed after treatment or at 6-12 month intervals if no cause is identified, to ensure that the hematuria has resolved and to detect any potential recurrence, as recommended by the American Family Physician 1.

From the Research

Evaluation of Hematuria

The evaluation of hematuria (blood in urine) involves a series of tests and procedures to determine the underlying cause of the condition. According to 2, the American Urological Association recommends cystoscopy and abdomino-pelvic imaging for patients aged more than 35 years.

Initial Evaluation

The initial evaluation of hematuria typically includes:

• Urinalysis to confirm the presence of blood in the urine
• Urine culture to rule out urinary tract infection
• Cystoscopy to visualize the inside of the bladder and urethra
• Renal ultrasound or intravenous pyelography (IVP) to evaluate the kidneys and ureters 3, 4

Further Evaluation

For patients with persistent microhematuria, further evaluation may include:

• Repeat urinalysis and urine culture
• Cystoscopy and renal ultrasound or IVP if not already performed
• Computed tomography (CT) urography if the patient meets the American Urological Association criteria for radiologic evaluation 5
• Renal biopsy or electron microscopy in rare cases where the cause of hematuria is unclear 6

Factors Associated with Evaluation

Several factors are associated with the evaluation of hematuria, including:

• Age: older patients are more likely to undergo evaluation 2
• Gender: men are more likely to undergo evaluation than women 2
• Anticoagulant use: patients taking anticoagulants are more likely to undergo evaluation 2
• Practice site: variation in evaluation rates has been observed between different practice sites 2