Urologic Evaluation with Cystoscopy and Upper Tract Imaging
This older man with smoking history and painless gross hematuria requires urgent urologic referral for cystoscopy and upper tract imaging (CT urography) to evaluate for urinary tract malignancy, which carries a 30-40% risk in gross hematuria. 1, 2
Why Immediate Urologic Evaluation is Critical
- Gross hematuria is a medical emergency requiring urgent evaluation, even if self-limited, due to the high malignancy risk 2, 3
- Painless gross hematuria has stronger association with cancer than hematuria with pain, which may suggest stone disease 2
- This patient has multiple high-risk features that mandate complete evaluation 1:
- Age >60 years (high-risk factor for urologic malignancy)
- Smoking history (significant risk factor for bladder and upper tract cancers)
- Male sex (higher prevalence of significant urologic disease)
- Gross hematuria (30-40% malignancy risk vs. 2.6-4% for microscopic)
The Complete Urologic Workup Includes
Cystoscopy (Essential)
- Direct visualization of the bladder to identify masses, carcinoma in situ, or other lesions 1, 2
- Also evaluates for urethral stricture disease and benign prostatic hyperplasia 1
Upper Tract Imaging
- CT urography is the preferred imaging modality for comprehensive evaluation of kidneys and ureters 1, 2
- Identifies hydronephrosis, urinary calculi, and renal/ureteral lesions 1
- MR urography is an alternative if CT is contraindicated 2
Additional Testing
- Urine cytology may be considered if there are risk factors for carcinoma in situ or irritative voiding symptoms 1
- Renal function tests and urinalysis with microscopic examination 1, 2
Critical Pitfalls to Avoid
- Do NOT delay urologic referral even if hematuria resolves spontaneously - malignancy can present with intermittent bleeding 2, 3
- Do NOT attribute hematuria solely to antiplatelet or anticoagulant medications without complete evaluation 2, 3
- Do NOT wait for other test results before making the urgent urology referral 2
- Do not rely on dipstick alone - the absence of casts and normal-appearing RBCs suggests non-glomerular (urologic) source rather than renal parenchymal disease 4
Why Nephrology Referral is NOT Indicated Here
The urinalysis shows RBCs without casts, which indicates a non-glomerular (urologic) source 4, 2. Nephrology referral would be appropriate only if there were 4:
- Red cell casts (pathognomonic for glomerular bleeding)
- Dysmorphic RBCs (>80% suggests glomerular origin)
- Significant proteinuria (>500-1000 mg/24 hours)
- Elevated serum creatinine
Expected Timeline
Urologic evaluation should occur urgently - this is not a routine outpatient referral 2. Early detection of urologic malignancy significantly impacts mortality and morbidity, and evaluation should not be delayed in high-risk patients 1.