What is the initial workup for a male patient presenting with acute hematuria?

Initial Workup for Male Patient with Acute Hematuria

For a male patient presenting with acute blood in urine (hematuria), a comprehensive urologic evaluation is mandatory due to the high risk of underlying malignancy (30-40% with gross hematuria). 1, 2

Classification and Initial Assessment

• Determine if hematuria is gross (visible) or microscopic (detected only on testing) as this affects risk stratification and urgency of evaluation 2
• Confirm hematuria with microscopic examination of urine, as dipstick tests have limited specificity (65-99%) and can yield false positives 2
• Rule out benign causes including infection, vigorous exercise, trauma, and certain medications 2
• Assess for risk factors for urologic malignancy: male gender, age >35 years, smoking history, occupational exposure to chemicals, analgesic abuse, history of urologic disease, irritative voiding symptoms, history of pelvic irradiation, chronic UTI, exposure to carcinogens, and chronic indwelling foreign bodies 1

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 and degree of proteinuria
  • Evidence of urinary tract infection (pyuria, bacteriuria) 2
• Urine culture to rule out infection 2
• Serum creatinine to assess renal function 2
• Urine cytology, particularly in high-risk patients 3

Determining the Source of Hematuria

• Glomerular source indicators: significant proteinuria (>500 mg/24 hours), dysmorphic red blood cells, red cell casts, elevated serum creatinine 2
• Non-glomerular (urologic) source indicators: normal-shaped RBCs, minimal or no proteinuria, normal serum creatinine 2

Imaging Recommendations

• CT urography (CTU) is the preferred imaging modality for comprehensive evaluation of the upper urinary tract in patients with gross hematuria 1, 2
• CTU involves unenhanced images followed by IV contrast-enhanced images, including nephrographic and excretory phases 1
• If CT is contraindicated, MR urography can be considered as an alternative 3
• For lower-risk patients or when radiation exposure is a concern, renal and bladder ultrasound can be used as an initial imaging test 2

Cystoscopy Recommendations

• Cystoscopy is indicated for all patients with gross hematuria regardless of age 2, 3
• Flexible cystoscopy is preferred over rigid cystoscopy due to less pain and fewer post-procedure symptoms 2

Specialist Referral

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

Common Pitfalls to Avoid

• Do not attribute hematuria solely to antiplatelet or anticoagulant medications without further investigation 2, 3
• Do not assume benign prostatic hyperplasia is the cause of hematuria without proper evaluation 2
• Do not delay urologic referral for patients with gross hematuria while waiting for other test results 2, 3
• Do not rely solely on dipstick results without microscopic confirmation 2
• Do not fail to evaluate asymptomatic microhematuria, as it may indicate serious underlying pathology 1, 4

Follow-up Recommendations

• For patients with a negative initial evaluation of asymptomatic microscopic hematuria, repeat urinalysis at 6,12,24, and 36 months 2
• For persistent asymptomatic microhematuria after negative urologic workup, yearly urinalyses should be conducted 1
• Consider repeat evaluation within three to five years for persistent or recurrent asymptomatic microhematuria after initial negative urologic workup 1