What is the best initial diagnostic approach for a patient presenting with hematuria (blood in urine) and bladder pain?

Best Diagnostic for Hematuria and Bladder Pain

For a patient presenting with hematuria and bladder pain, ultrasound of the kidneys and bladder is the recommended initial diagnostic test, with CT (unenhanced for suspected stones, or contrast-enhanced CT urography for other etiologies) reserved for cases where ultrasound is negative but clinical suspicion remains high or when ultrasound findings require further characterization.

Clinical Context and Differential Diagnosis

The combination of hematuria and bladder pain in a nontraumatic setting most commonly suggests urolithiasis as the primary differential diagnosis, though tumor and ureteropelvic junction obstruction must also be considered 1. The diagnostic approach differs significantly based on whether the presentation is in a pediatric or adult patient, and whether trauma is involved.

Initial Diagnostic Approach

For Suspected Urolithiasis (Most Common with Pain)

Ultrasound of kidneys and bladder is the appropriate first-line imaging modality 1:

• US found 75% of all urinary tract stones in one study, though sensitivity for ureteral stones is lower (38%) 1
• Provides radiation-free evaluation, particularly important in children and young adults
• Can identify hydronephrosis, renal masses, and bladder abnormalities
• Should be performed with a distended bladder for optimal assessment 1

CT without contrast becomes the definitive test when:

• Ultrasound is negative but clinical suspicion for urolithiasis remains high 1
• Detection would impact treatment decisions 1
• CT demonstrates sensitivity and specificity both well above 90% for stone detection 1
• Modern low-dose CT protocols with iterative reconstruction can achieve radiation doses lower than traditional IVU 1

For Non-Stone Etiologies

Contrast-enhanced CT urography is indicated when 2, 3, 4:

• Renal mass is detected on ultrasound requiring further characterization 1
• Recurrent hematuria with negative ultrasound and extensive clinical workup 1
• High suspicion for urothelial malignancy (particularly in adults with risk factors)
• The protocol includes unenhanced, nephrographic-phase, and excretory-phase imaging 2, 4

Age-Specific Considerations

Pediatric Patients

• Ultrasound is strongly preferred as first-line to avoid radiation exposure 1
• CT is reserved for negative ultrasound with persistent symptoms or when findings require further evaluation 1
• Upper urinary tract urothelial neoplasia is extremely rare in children, making extensive imaging less urgent 1

Adult Patients

• CT urography has become the preferred comprehensive examination for high-risk patients 3
• Risk of malignancy with gross hematuria exceeds 10%, warranting more aggressive imaging 5
• CT urography can replace the combination of multiple traditional tests (IVU, ultrasound, retrograde studies) 2, 3

Trauma-Related Hematuria with Bladder Pain

If trauma is present (even minor trauma with bladder pain):

Contrast-enhanced CT is the gold standard 1:

• Required for all patients with gross hematuria and trauma 1
• Delayed scans should be obtained if renal injury is detected to evaluate collecting system disruption 1

CT cystography specifically indicated when 1:

• Gross hematuria occurs with pelvic fractures (high risk for bladder rupture) 1
• Performed after retrograde distention of bladder with iodinated contrast 1
• Images obtained with contrast-filled bladder; postvoid images may be unnecessary 1

Retrograde urethrography required before catheterization if 1:

• Blood present at urethral meatus
• Associated pelvic fractures or straddle injury
• May warrant subsequent cystogram to exclude concomitant bladder injury 1

Modalities NOT Appropriate for Initial Evaluation

The following should not be used as first-line tests for hematuria with bladder pain:

• Intravenous urography (IVU): No longer first-line; low sensitivity for renal masses and urinary tract abnormalities compared to CT 1
• MRI/MRU: Not appropriate for initial evaluation of painful hematuria 1
• VCUG: Not appropriate for initial evaluation 1
• Plain radiography (KUB): Only 59% sensitivity for stone detection; not first-line 1
• Arteriography: No role in initial evaluation 1

Critical Pitfalls to Avoid

• Do not skip imaging in pediatric trauma patients with only microscopic hematuria if they have congenital renal abnormalities, multiorgan injury, deceleration injury history, localized flank pain, or ecchymosis 1
• Do not catheterize patients with blood at urethral meatus before performing retrograde urethrography 1
• Do not rely solely on ultrasound in trauma settings with gross hematuria—US has only 41% diagnostic accuracy for all renal injury types 1
• Do not assume microscopic hematuria excludes significant injury in children—37.5% of children with grades 2-5 renal injuries did not have macroscopic hematuria 1

Subsequent Workup

If imaging is negative but hematuria persists 1:

• Cystoscopy may be indicated for suspected bladder urothelial neoplasm
• Urologic referral recommended for patients with risk factors for malignancy 5, 6
• Laboratory evaluation for intrinsic renal disease if microscopic hematuria with proteinuria 5