What is the management plan for a 44-year-old patient with lower abdominal pain, dysuria (burning pain when urinating), frequent urination, and hematuria (blood in urine) with proteinuria (protein in urine) but no leukocytes or nitrites?

Management of 44-Year-Old with Hematuria, Proteinuria, and Dysuria

This patient requires urgent evaluation for urinary tract infection (UTI) first, followed by comprehensive urologic and nephrologic assessment if symptoms persist after treatment, as the combination of hematuria with proteinuria and dysuria suggests either infection or potentially serious underlying pathology requiring specialist evaluation. 1, 2

Immediate Actions

Rule Out UTI Despite Negative Leukocytes/Nitrites

• Obtain a urine culture immediately before starting antibiotics, as the absence of leukocytes and nitrites does NOT exclude UTI—these markers have poor sensitivity, and symptomatic patients with dysuria and hematuria warrant culture regardless of dipstick results 3, 2
• The burning dysuria with frequency strongly suggests lower urinary tract irritation, which is most commonly infectious 4
• Treat empirically for UTI while awaiting culture results, given the classic triad of dysuria, frequency, and hematuria 4
• Repeat urinalysis 6 weeks after completing antibiotic therapy to confirm resolution of hematuria and proteinuria 2

Symptomatic Relief

• Consider phenazopyridine (urinary analgesic) for symptomatic relief of burning and urgency for maximum 2 days while awaiting culture results and antibiotic effect 5
• This provides symptomatic relief but does not delay definitive diagnosis and treatment 5

If Hematuria and Proteinuria Persist After UTI Treatment

Determine Glomerular vs. Non-Glomerular Source

Critical diagnostic step: Examine urinary sediment for dysmorphic RBCs and red cell casts 1, 2

Indicators of Glomerular Source:

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

Indicators of Non-Glomerular (Urologic) Source:

• Normal-shaped RBCs >80% 1
• Minimal proteinuria <500 mg/24 hours 1
• Normal serum creatinine 1

Quantify Proteinuria

• Obtain 24-hour urine collection to quantify protein excretion, as dipstick showing protein requires quantification 1, 2

Assess Renal Function

• Measure serum creatinine to evaluate baseline kidney function 1, 2

Specialist Referral Criteria

Immediate Nephrology Referral If:

• Proteinuria >1,000 mg/24 hours 1, 2
• Proteinuria >500 mg/24 hours that is persistent or increasing 1, 2
• Red cell casts present 1, 2
• Predominantly dysmorphic RBCs (>80%) 1, 2
• Elevated serum creatinine 1

Urology Referral If:

• Age >40 years (this patient is 44) 2
• History of gross hematuria 2
• Smoking history 2
• Occupational exposure to chemicals/dyes 2
• Recurrent UTIs 2
• Irritative voiding symptoms (frequency, urgency) 2
• Known fibroids causing urinary tract obstruction 3

Additional Imaging Considerations

Renal Ultrasound

• Perform renal and bladder ultrasound to evaluate for structural abnormalities, masses, stones, or fibroid-related compression of urinary tract 3, 1
• Particularly important given patient's known fibroids and lower abdominal pain 3

Critical Pitfalls to Avoid

• Never attribute hematuria solely to fibroids without complete urologic evaluation—fibroids can cause pelvic pressure but hematuria with proteinuria requires investigation for other causes 6, 1
• Do not dismiss hematuria because leukocytes/nitrites are negative—these have poor negative predictive value for UTI in symptomatic patients 3, 2
• Anticoagulation or antiplatelet therapy (if present) is NOT a reason to forgo evaluation—these medications may unmask underlying pathology but do not cause hematuria 6
• Gross hematuria (if it occurs) requires urgent urologic referral even if self-limited, as it carries 30-40% malignancy risk 6, 2

Follow-Up Protocol

If initial evaluation is negative but hematuria/proteinuria persists:

• Repeat urinalysis at 6,12,24, and 36 months 2
• Monitor blood pressure at each visit 2
• Reconsider nephrology referral if hematuria persists with development of hypertension, worsening proteinuria, or evidence of glomerular bleeding 2