Evaluation and Management of Visible (Gross) Hematuria
All patients with visible hematuria require urgent urologic referral for cystoscopy and upper tract imaging, regardless of whether the bleeding is self-limited or the patient is on anticoagulation. 1, 2
Why Gross Hematuria Demands Immediate Action
Visible hematuria carries a 30-40% risk of underlying malignancy, which is dramatically higher than microscopic hematuria (2.6-4% risk). 3 This substantial cancer risk mandates complete urologic evaluation even when bleeding resolves spontaneously. 1, 2
Critical pitfall: Anticoagulation or antiplatelet therapy should never be accepted as the sole explanation for gross hematuria—these medications may unmask underlying pathology but do not cause hematuria themselves. 1, 3
Initial Workup Before Urologic Referral
While arranging urgent urology consultation, perform these baseline assessments:
Confirm True Hematuria
- Obtain microscopic urinalysis to confirm presence of red blood cells (≥3 RBCs per high-power field), as dipstick alone can yield false positives from myoglobinuria, hemoglobinuria, or menstrual contamination. 1, 2
Rule Out Transient Benign Causes
- If urinary tract infection suspected: Obtain urine culture before antibiotics, treat if positive, then repeat urinalysis 6 weeks post-treatment to confirm hematuria resolution. 2
- If menstruation, vigorous exercise, or viral illness present: Repeat urinalysis 48 hours after cessation of the potential cause. 2
- Important caveat: Even if a benign cause is identified initially, persistent or recurrent gross hematuria still requires full urologic evaluation. 1
Assess for Glomerular vs. Non-Glomerular Source
- Examine urinary sediment for dysmorphic RBCs (>80% suggests glomerular origin) and red cell casts. 2, 3
- Check for significant proteinuria (>500 mg/24 hours suggests renal parenchymal disease). 2, 3
- Measure serum creatinine to assess renal function. 2
- Tea-colored urine suggests glomerular bleeding. 3
Required Urologic Evaluation
The complete urologic workup includes:
Cystoscopy
- Direct visualization of bladder and urethra to identify bladder tumors, stones, or other mucosal lesions. 1, 4
- Required for all patients with gross hematuria regardless of age. 1, 4
Upper Tract Imaging
- CT urography (with and without contrast) is the preferred imaging modality, with 92% sensitivity and 93% specificity for detecting urologic pathology. 1, 4
- Alternative options include renal ultrasound (50% sensitivity, 95% specificity) or MRI if CT is contraindicated. 1, 4
Urine Cytology
- Particularly important for detecting high-grade urothelial carcinoma, though sensitivity is limited (37%). 4
When to Involve Nephrology
Refer to nephrology in addition to (not instead of) urology if any of these features suggest medical renal disease: 1, 2
- Proteinuria >500 mg/24 hours
- Dysmorphic RBCs >80%
- Red blood cell casts
- Elevated serum creatinine
- Hypertension developing with persistent hematuria
Key point: Glomerular disease does not exclude concurrent urologic malignancy—both evaluations must proceed. 1
Special Populations
Women
Women are significantly underreferred for hematuria evaluation (8-28% referral rate vs. 36-47% in men) and experience longer delays to diagnosis. 1 Despite lower overall bladder cancer incidence, women present with more advanced disease and higher mortality, making timely evaluation equally critical. 1
Patients on Anticoagulation
These patients have higher risk of recurrent bleeding but the same underlying cancer risk as others. 5 Do not delay or omit evaluation based on anticoagulation status. 1
Critical Clinical Pearl
Approximately 20% of patients referred for microscopic hematuria report a history of visible hematuria when specifically asked, yet this symptom is commonly underreported. 1 Always explicitly ask about any episodes of visible blood in urine during review of systems, as this history significantly increases cancer risk (odds ratio 7.2) and changes management. 2