What is the evaluation and management for a patient with diabetes and hematuria?

Evaluation and Management of Hematuria in a 68-Year-Old Female with Diabetes

This patient requires urgent urologic evaluation with cystoscopy and upper tract imaging (CT urogram preferred) due to significant hematuria (10 RBCs/HPF) in a high-risk individual (age >60 years with diabetes), as microscopic hematuria in this demographic carries substantial malignancy risk. 1

Risk Stratification

This patient falls into the intermediate-to-high risk category based on the 2025 AUA/SUFU risk stratification system 1:

• Age: 68 years (women ≥60 years = intermediate risk minimum) 1
• Degree of hematuria: 10 RBCs/HPF (falls in 3-10 range, but combined with age elevates concern) 1
• Diabetes: While not explicitly listed as a primary risk factor in stratification, diabetic patients can have hematuria from diabetic nephropathy, but this should never be assumed without excluding malignancy first 2, 3, 4

Critical point: Even though hematuria can occur in diabetic nephropathy (present in 13-35% of diabetic patients with nephropathy), this finding mandates full urologic evaluation to exclude urothelial malignancy before attributing it to diabetes alone 2, 3, 4

Immediate Evaluation Steps

1. Confirm True Hematuria

• Microscopic examination is already completed showing 10 RBCs/HPF, confirming true hematuria (≥3 RBCs/HPF threshold met) 5
• Rule out benign causes: menstruation (unlikely at age 68), recent vigorous exercise, sexual activity, or urinary tract infection 5

2. Obtain Urine Culture

• If UTI suspected, obtain culture and treat appropriately 5
• Repeat urinalysis 6 weeks after treatment; if hematuria resolves, no further urologic evaluation needed 1, 5
• However, given age and risk factors, even transient resolution should prompt consideration of evaluation 1

3. Assess for Glomerular vs. Non-Glomerular Source

Examine urinary sediment for 5:

• Dysmorphic RBCs (>80% suggests glomerular source) 5
• Red cell casts (indicate glomerular disease) 5
• Proteinuria quantification (>500 mg/24 hours suggests glomerular) 5

This patient's urinalysis shows:

• Protein: negative (argues against significant glomerular disease)
• No mention of casts or dysmorphic RBCs
• This pattern suggests non-glomerular (urologic) source requiring cystoscopy and imaging 5

4. Check Serum Creatinine and Blood Pressure

• Already part of initial evaluation 1, 5
• If elevated creatinine, proteinuria, or hypertension present with glomerular features → nephrology referral 5

Required Urologic Evaluation

Cystoscopy

Mandatory for this patient 1:

• All patients ≥60 years with microscopic hematuria should undergo cystoscopy 1
• Flexible cystoscopy preferred (less painful, equivalent diagnostic accuracy) 1
• Can be performed under local anesthesia in office setting 1
• Do not defer cystoscopy even if imaging is negative, as bladder cancer is the most common malignancy detected in hematuria patients and optimally diagnosed by cystoscopy 1

Upper Tract Imaging

CT urogram is the preferred modality 1:

• Best for detecting renal cell carcinoma, transitional cell carcinoma, urolithiasis, and renal infections 1
• Superior to intravenous urography (IVU) for small renal masses 1
• Provides comprehensive evaluation of kidneys, ureters, and bladder 1

Alternative if CT contraindicated: Intravenous urography remains acceptable but has limitations in detecting small renal masses 1

Urinary Cytology

Consider in this patient 1:

• Useful adjunct to cystoscopy, especially for detecting carcinoma in situ 1
• High specificity for high-grade urothelial carcinoma 1
• Recommended for patients with risk factors for transitional cell carcinoma 1

Special Considerations for Diabetic Patients

Do not attribute hematuria solely to diabetes 2, 3, 4:

• While 13-35% of diabetic nephropathy patients have microscopic hematuria, this is a diagnosis of exclusion 2, 3
• Hematuria in diabetics is associated with longer diabetes duration (>10 years), retinopathy, and proteinuria 3, 4
• Red cell casts occur in 13-34% of diabetic nephropathy patients with hematuria 2, 4
• If glomerular features present (dysmorphic RBCs, casts, significant proteinuria), consider renal biopsy after urologic evaluation is negative 2, 4

Follow-Up After Negative Evaluation

If initial evaluation is completely negative 1:

• Repeat urinalysis, cytology, and blood pressure at 6,12,24, and 36 months 1
• Immediate re-evaluation required if: gross hematuria develops, abnormal cytology, or irritative voiding symptoms without infection 1
• If no concerning findings within 3 years, discontinue urologic monitoring 1

Common Pitfalls to Avoid

1. Never assume hematuria is from diabetes without full urologic evaluation 2, 3, 4
2. Do not rely solely on imaging—cystoscopy is essential for bladder cancer detection 1
3. Do not defer evaluation in patients on anticoagulation—hematuria in anticoagulated patients still requires investigation 1, 5
4. Do not use dipstick alone—always confirm with microscopic examination 5
5. Delays in bladder cancer diagnosis increase mortality by 34%—prompt referral is critical 1