What are the next steps for a patient with hematuria and abnormal urinalysis results?

Management of Hematuria with Abnormal Urinalysis

This patient requires risk stratification followed by urologic evaluation with cystoscopy and upper tract imaging, as the urinalysis shows microscopic hematuria (3-10 RBC/HPF) with 2+ occult blood and an elevated pH of 8.5. 1

Immediate Assessment Steps

Confirm True Hematuria

• Verify microscopic hematuria is present with 3-10 RBC/HPF on microscopy, which meets the diagnostic threshold of ≥3 RBC/HPF 2
• The 2+ occult blood on dipstick correlates with the microscopic findings, confirming true hematuria 2

Exclude Benign Causes

• Rule out urinary tract infection with urine culture, though the negative leukocyte esterase and nitrites make infection unlikely 1, 2
• Obtain history of recent vigorous exercise, trauma, menstruation (if applicable), or medications that could cause transient hematuria 1
• If a benign cause is identified, repeat urinalysis 48 hours after cessation of the cause or 6 weeks after treating infection 2

Assess for Glomerular vs Non-Glomerular Source

• This patient shows non-glomerular hematuria: normal-shaped RBCs (not dysmorphic), no protein, no red cell casts, and no evidence of renal dysfunction 1
• The elevated pH (8.5) may suggest urinary alkalinization but does not indicate glomerular disease 1
• Measure serum creatinine to assess renal function 1, 2

Risk Stratification for Malignancy

Determine the patient's risk category based on the 2025 AUA/SUFU guidelines to guide the intensity of evaluation:

High-Risk Factors

• Age >40 years 2
• Smoking history (current or former) 2
• Degree of hematuria >25 RBC/HPF (this patient has 3-10 RBC/HPF, which is low-moderate) 3
• History of gross hematuria 3
• Occupational exposure to chemicals/dyes (benzenes, aromatic amines) 2
• Irritative voiding symptoms without infection 2
• History of pelvic irradiation 2

Important Caveat

Do not attribute hematuria solely to anticoagulant or antiplatelet therapy without complete evaluation, as these medications may unmask underlying pathology rather than cause it 1, 3

Urologic Evaluation Protocol

For Patients with Risk Factors

Proceed with comprehensive urologic workup including:

• Cystoscopy to evaluate the bladder and urethra for malignancy or other lesions 1, 3
• CT urography as the preferred imaging modality for comprehensive upper tract evaluation (kidney, ureters) 1, 3
  • Alternative: MR urography if CT is contraindicated 1
  • Alternative: Renal ultrasound with retrograde pyelography if CT/MR not feasible 1

Urine Cytology Considerations

The 2025 AUA/SUFU guidelines recommend against routine urine cytology in initial evaluation, though it may be considered in high-risk patients 1

• Urine-based tumor markers are evolving but not yet standard of care 4

Follow-Up Strategy

After Negative Initial Evaluation

If the complete workup is negative, engage in shared decision-making regarding surveillance 4:

• Most patients with negative risk-stratified evaluation do not require ongoing urologic monitoring and may be safely discharged 4
• For select high-risk patients (heavy smoking history, multiple risk factors), consider repeat urinalysis at 6,12,24, and 36 months 4, 2
• Monitor blood pressure at follow-up visits 2

Triggers for Re-evaluation

Immediate urologic re-evaluation is mandatory if any of the following develop 4, 1:

• Recurrent gross hematuria 1
• New or worsening urologic symptoms 4
• Higher degree of microscopic hematuria on repeat testing 4
• Development of hypertension, proteinuria, or evidence of glomerular bleeding (requires nephrology referral) 1, 2

Critical Pitfalls to Avoid

• Never delay urologic evaluation in patients with gross hematuria, even if self-limited, as malignancy risk exceeds 10% 1
• Do not assume benign prostatic hyperplasia or medications explain the hematuria without proper evaluation 1, 3
• Do not omit cystoscopy based on age alone; risk stratification should guide evaluation intensity 3
• After a benign etiology is found (e.g., BPH, non-obstructing stones), persistent stable hematuria still warrants shared decision-making about repeat evaluation based on time elapsed and risk factors 4