What are the recommended steps for diagnosing and treating chronic hematuria and dysuria when the bladder fills?

Chronic Trace Hematuria with Bladder Filling Pain: Diagnosis and Management

This presentation of chronic trace hematuria with pain specifically during bladder filling strongly suggests interstitial cystitis/bladder pain syndrome (IC/BPS), which requires a clinical diagnosis based on symptoms present for at least 6 weeks with negative urine cultures, followed by individualized multimodal treatment starting with conservative measures. 1

Initial Diagnostic Workup

Essential Clinical Assessment

• Document symptom duration of at least 6 weeks with negative urine cultures to establish chronicity required for IC/BPS diagnosis 1
• Record the number of voids per day, sensation of constant urge to void, and the specific location, character, and severity of pain/pressure/discomfort 1
• Note the relationship of pain to bladder filling specifically, as this is characteristic of IC/BPS 1
• Perform a brief neurological exam to rule out occult neurologic problems 1
• Evaluate for incomplete bladder emptying to exclude occult retention 1

Mandatory Laboratory Testing

• Urinalysis with microscopic examination to confirm trace hematuria (>5 RBCs/high power field) and assess for infection 2, 3
• Urine culture is indicated even with negative urinalysis dipstick, as lower bacterial levels may be clinically significant but not detectable on dipstick 1
• Obtain a one-day voiding log at minimum to establish the low-volume frequency voiding pattern characteristic of IC/BPS 1
• Measure baseline pain levels using validated tools (GUPI, ICSI, or VAS) to track treatment response 1

Critical Hematuria Evaluation

A proper hematuria workup must be performed given the trace blood, and is especially important with any tobacco exposure due to high bladder cancer risk in smokers 1. However, the chronic nature with bladder-filling pain pattern makes IC/BPS more likely than malignancy.

Role of Cystoscopy

When Cystoscopy is Indicated

• Perform cystoscopy if Hunner lesions are suspected, as this is the only consistent cystoscopic finding diagnostic for IC/BPS 1
• Cystoscopy is also indicated to exclude bladder cancer, stones, or intravesical foreign bodies that could mimic IC/BPS 1
• Early cystoscopy is recommended in suspected Hunner lesion cases without requiring failure of other treatments first, as most patients with Hunner lesions respond to specific treatment 1

When Cystoscopy is NOT Routinely Needed

• There are no agreed-upon cystoscopic findings diagnostic for IC/BPS except Hunner lesions 1
• For uncomplicated patients without red flags for malignancy, cystoscopy is not required in initial workup 1

What NOT to Do (Common Pitfalls)

Avoid Routine Urodynamics

• Urodynamics are not recommended for routine clinical use to establish IC/BPS diagnosis 1
• Consider urodynamics only if suspecting outlet obstruction, poor detrusor contractility, or when patients are refractory to behavioral/medical therapies 1

Do Not Delay Evaluation

• Do not attribute hematuria solely to medications without full evaluation 2
• Even trace/microscopic hematuria requires assessment, though the risk of malignancy is lower (2.6-4%) compared to gross hematuria (30-40%) 2

Treatment Approach for IC/BPS

Initial Management Strategy

• Initial treatment should typically be nonsurgical except for patients with Hunner lesions 1
• Concurrent, multimodal therapies may be offered simultaneously 1
• Treatment must be individualized based on each patient's unique characteristics and phenotype 1

Specific Considerations

• If Hunner lesions are identified on cystoscopy, these patients respond well to specific treatment and should receive it promptly 1
• The clinical approach needs to progress from conservative measures through medications, procedures, and only to major surgery as a last resort 1

Follow-Up Protocol

For Negative Initial Evaluation

• Repeat urinalysis at 6,12,24, and 36 months if initial workup is negative 2
• Monitor blood pressure at each visit 2
• Consider nephrology referral if hematuria persists with development of hypertension, proteinuria, or evidence of glomerular bleeding (dysmorphic RBCs, red cell casts) 2

Red Flags Requiring Immediate Reevaluation

• Recurrent gross hematuria 2
• Abnormal urinary cytology 2
• Irritative voiding symptoms in the absence of infection 2