What are the next steps for a patient with hematuria and slightly concentrated urine?

Immediate Next Steps for Hematuria with Back Pain and Dark Urine

This patient requires urgent urologic referral for cystoscopy and upper tract imaging (CT urography preferred) to rule out malignancy, urolithiasis, or other serious urologic pathology. 1, 2, 3

Initial Confirmation and Assessment

• Confirm true hematuria by repeating microscopic urinalysis to verify ≥3 RBCs per high-power field, as dipstick alone has limited specificity (65-99%). 2, 4

• Rule out benign transient causes before proceeding with extensive workup:

  • Obtain urine culture to exclude urinary tract infection (UTI), as infection is a common benign cause. 2, 4
  • If UTI is confirmed, treat appropriately and repeat urinalysis 6 weeks after treatment to confirm resolution. 4
  • Consider recent vigorous exercise, menstruation (if female), or trauma as potential transient causes. 2, 4

• Assess for glomerular versus non-glomerular source by examining urinary sediment:

  • Look for dysmorphic RBCs (>80% suggests glomerular), red cell casts, and significant proteinuria (>500 mg/24 hours). 2, 4
  • Check serum creatinine to assess renal function. 4, 3
  • The combination of moderate blood with pH 5.5 and specific gravity 1.025 suggests concentrated urine, possibly from mild dehydration, but does not exclude serious pathology. 2

Risk Stratification for Malignancy

This patient has multiple concerning features requiring urgent evaluation:

• Moderate hematuria (not just trace) increases malignancy risk. 1
• Back/flank pain with hematuria raises concern for urolithiasis or upper tract malignancy. 3
• Dark urine suggests significant blood concentration. 3
• Urinary discomfort warrants immediate attention. 1

The 2025 AUA/SUFU guidelines stratify risk based on:

• Degree of hematuria (3-10 RBC/HPF = low risk; 11-25 = intermediate; >25 = high risk) 2
• Age (women ≥60 years or men ≥40 years = higher risk) 2
• Smoking history (>30 pack-years = high risk) 2

Mandatory Urologic Workup

All patients with symptomatic hematuria (pain, discomfort) require complete urologic evaluation regardless of risk stratification. 1

Upper Tract Imaging

• CT urography (multiphasic CT with IV contrast) is the preferred imaging modality for comprehensive evaluation of kidneys, ureters, and bladder. 1, 2, 3
• CT is superior for detecting stones, masses, and renal/perirenal pathology. 1
• MR urography is an alternative if CT is contraindicated. 3

Lower Tract Evaluation

• Cystoscopy is mandatory to evaluate the bladder and urethra for malignancy, stones, or other pathology. 1, 2, 3
• Flexible cystoscopy is preferred over rigid cystoscopy due to less pain and equivalent diagnostic accuracy. 1

Additional Testing

• Urine cytology should be obtained in high-risk patients to detect high-grade transitional cell carcinoma. 1, 2
• Renal function tests (serum creatinine, BUN) are essential. 4, 3

Specialist Referral Criteria

Immediate urologic referral is indicated for:

• Any degree of gross hematuria (even if self-limited). 2, 4, 3
• Symptomatic microscopic hematuria with pain or urinary discomfort. 1
• Persistent microscopic hematuria without benign explanation. 2, 4

Nephrology referral is indicated if:

• Proteinuria >500 mg/24 hours is present. 4
• Dysmorphic RBCs (>80%), red cell casts, or elevated creatinine suggest glomerular disease. 2, 4, 3
• Hematuria persists with development of hypertension or worsening renal function. 1, 4

Critical Pitfalls to Avoid

• Never attribute hematuria solely to anticoagulation or antiplatelet therapy without complete evaluation, as these medications may unmask underlying pathology. 2, 4, 3
• Do not delay urologic referral even if hematuria resolves spontaneously, as bladder cancer can present with intermittent bleeding. 1, 3
• Do not assume infection is the cause without confirming with urine culture and documenting resolution after treatment. 4
• Do not ignore new or worsening symptoms (pain, discomfort), as these significantly increase the likelihood of clinically significant pathology. 1

Follow-Up Protocol (Only if Initial Workup is Negative)

If the complete urologic evaluation is negative:

• Repeat urinalysis, urine cytology, and blood pressure at 6,12,24, and 36 months. 1, 4, 3
• Immediate re-evaluation is required if gross hematuria recurs, cytology becomes abnormal, or irritative voiding symptoms develop. 1, 3
• After 3 years of negative follow-up without changes, further urologic monitoring may not be necessary, though shared decision-making should guide this. 1