What is the next step for a 36-year-old man presenting with hematuria?

Management of Hematuria in a 36-Year-Old Man

For a 36-year-old man presenting with hematuria, the next step should be a complete urologic evaluation including confirmation of microscopic hematuria with urinalysis, upper tract imaging with CT urography, and cystoscopy. 1, 2

Initial Assessment

• Confirm the presence of hematuria with microscopic examination of urinary sediment from a freshly voided, clean-catch, midstream urine specimen (threshold of ≥3 red blood cells per high-power field) 1, 2
• Exclude benign causes including infection, vigorous exercise, trauma, and medications 3, 2
• Obtain urine culture to rule out urinary tract infection as a potential cause 2
• Assess for signs of primary renal disease, including significant proteinuria, dysmorphic red blood cells, red cell casts, or elevated serum creatinine 1, 3

Risk Stratification

• At 36 years old, this patient is at the threshold for age-related risk for urologic malignancy (AUA guidelines recommend evaluation for patients with asymptomatic microscopic hematuria who are older than 35 years) 1
• Assess for additional risk factors including smoking history, occupational exposure to chemicals or dyes, history of gross hematuria, and irritative voiding symptoms 3, 2
• The risk of malignancy in patients with microscopic hematuria ranges from 2.6% to 4%, compared to 30-40% in those with gross hematuria 3, 4

Diagnostic Pathway

If Gross Hematuria:

• Urgent urologic referral is mandatory due to high risk of underlying malignancy (>10%), even if bleeding is self-limited 3, 4
• Do not attribute hematuria solely to antiplatelet or anticoagulant therapy if the patient is taking these medications 1, 3

If Microscopic Hematuria:

• Assess for glomerular versus non-glomerular source 1, 3
• Glomerular source is likely if there is significant proteinuria, dysmorphic RBCs, red cell casts, or elevated serum creatinine 3
• Non-glomerular (urologic) source is likely if there are normal-shaped RBCs, minimal or no proteinuria, and normal serum creatinine 3

Recommended Evaluation

• Upper Tract Imaging: CT urography is the preferred imaging modality for comprehensive evaluation of the upper urinary tract 1, 3
• Cystoscopy: Direct visualization of the bladder mucosa, urethra, and ureteral orifices 3, 2
• Laboratory Tests: Serum creatinine to assess renal function 3, 2

Specialist Referral

• Urologic Referral: Indicated for all patients with gross hematuria, patients with microscopic hematuria at age 36 with risk factors, or if no benign cause is identified 1, 3
• Nephrology Referral: Consider if there is evidence of glomerular disease (proteinuria, red cell casts, or predominantly dysmorphic RBCs) 3, 2

Follow-up Recommendations

• If initial evaluation is negative, repeat urinalysis at 6,12,24, and 36 months 3, 2
• Monitor blood pressure and consider nephrology referral if hematuria persists with development of hypertension, proteinuria, or evidence of glomerular bleeding 3, 2
• Immediate urologic reevaluation is warranted if any of the following occur: gross hematuria, abnormal urinary cytology, or irritative voiding symptoms in the absence of infection 2

Common Pitfalls to Avoid

• Do not attribute hematuria solely to antiplatelet or anticoagulant therapy without further investigation 1, 3
• Do not delay urologic referral while waiting for other test results in a patient with gross hematuria 3
• Do not assume that a single negative urinalysis excludes significant pathology, as hematuria from cancer can be intermittent 1