What is the evaluation and treatment approach for hematuria (presence of blood in urine) in males?

Evaluation and Management of Hematuria in Males

Initial Assessment and Risk Stratification

All males with gross (visible) hematuria require urgent urologic referral for cystoscopy and upper tract imaging, regardless of age or whether bleeding has resolved, due to a 30-40% risk of underlying malignancy. 1

For microscopic hematuria, risk stratification determines the evaluation pathway:

Confirm True Hematuria

• Verify ≥3 red blood cells per high-power field (RBC/HPF) on microscopic examination of urinary sediment from 2 of 3 properly collected specimens 2, 3
• Never rely on dipstick alone—it has limited specificity (65-99%) and can yield false positives from myoglobinuria, hemoglobinuria, or contamination 3, 1

Exclude Benign Transient Causes

• Rule out urinary tract infection with urine culture; if positive, treat and repeat urinalysis 6 weeks post-treatment to confirm resolution 4, 1
• Consider recent vigorous exercise, sexual activity, viral illness, or trauma 3, 4
• Repeat urinalysis 48 hours after cessation of the suspected benign cause 4

Assess for Primary Renal Disease

Nephrology referral (in addition to urologic evaluation) is indicated if any of the following are present:

• Significant proteinuria >500-1,000 mg/24 hours 2, 3, 4
• Dysmorphic RBCs >80% or red cell casts 2, 3, 4
• Elevated serum creatinine 2, 3
• Hypertension developing with persistent hematuria 4, 1

Critical caveat: Glomerular disease does not exclude concurrent urologic malignancy—both nephrology and urology evaluations must proceed. 1

Risk-Based Urologic Evaluation for Microscopic Hematuria

High-Risk Patients (Require Complete Urologic Evaluation)

Males are high-risk if they have any of the following:

• Age ≥60 years 2, 3
• Age 40-59 years with additional risk factors 2
• Smoking history (particularly >10 pack-years) 2, 3, 4
• Occupational exposure to benzenes or aromatic amines 2, 4
• History of gross hematuria 2

• 25 RBC/HPF on single urinalysis 2

• History of pelvic irradiation 4
• Irritative voiding symptoms 2, 4
• Previous urologic disorder 2

Complete Urologic Evaluation Components

For high-risk patients with microscopic hematuria or any patient with gross hematuria:

Imaging:

• Multiphasic CT urography (preferred) to identify hydronephrosis, urinary calculi, and renal/ureteral lesions with 92% sensitivity and 93% specificity 3, 1
• A combination of ultrasound and IVP is necessary if CT is contraindicated, as either modality alone misses upper tract tumors 5

Cystoscopy:

• Mandatory for all males with gross hematuria regardless of age 1, 5
• Required for high-risk microscopic hematuria to evaluate for bladder masses, urethral stricture, and benign prostatic hyperplasia 3
• Cannot be safely avoided even in younger patients—bladder cancer was found in 7 patients younger than 40 years in one prospective series 5
• For males under 40 with high-grade microscopic hematuria (>25 RBC/HPF), cystoscopy detected malignancy in 20% of cases 6

Additional Testing:

• Urine cytology if risk factors for carcinoma in situ or irritative voiding symptoms are present 3
• Renal function tests and inflammatory parameters 3

Lower-Risk Patients

Males age 40-59 years with 3-10 RBC/HPF, never smoker or <10 pack-years, and no additional risk factors may undergo shared decision-making regarding the intensity of evaluation versus repeat urinalysis 2, 3

Common Pitfalls to Avoid

• Never attribute gross hematuria solely to anticoagulation or antiplatelet therapy—these medications may unmask underlying pathology but do not cause hematuria themselves 4, 1
• Do not skip cystoscopy based on age alone—malignancy occurs even in younger males with microscopic hematuria 5, 6
• Random bladder biopsies in the absence of visible lesions have no diagnostic role and should not be performed 6
• Males are significantly more likely to receive appropriate evaluation than females (36-47% vs 8-28% referral rates), but many males still remain under-evaluated 1, 7

Follow-Up After Negative Evaluation

If initial complete evaluation is negative but microscopic hematuria persists:

• Repeat urinalysis at 6,12,24, and 36 months 4
• Initiate further evaluation if patient develops gross hematuria, significant increase in degree of microscopic hematuria, or new urologic symptoms 2, 3
• Consider shared decision-making regarding additional testing for persistent microscopic hematuria 2, 3

The risk of malignancy increases with the degree of hematuria (number of RBCs per HPF), and early detection significantly impacts mortality and morbidity—evaluation should not be delayed in high-risk patients. 3