What is the appropriate management for a patient presenting with frank hematuria?

Management of Frank (Gross) Hematuria

All adults presenting with frank hematuria require urgent urologic referral for comprehensive evaluation including cystoscopy and imaging, even if the bleeding is self-limited, due to the high risk of underlying malignancy (>10% and up to 25-40% in referral series). 1

Immediate Assessment and Risk Stratification

Critical First Steps

• Document the character of hematuria: Painless gross hematuria has a stronger association with malignancy than hematuria with flank pain (which suggests urolithiasis). 1
• Do NOT delay evaluation based on anticoagulant or antiplatelet therapy—these medications may unmask underlying pathology but do not cause hematuria themselves. 1
• Obtain focused history for risk factors: age >35 years, smoking history (especially >30 pack-years), occupational chemical/dye exposure, prior pelvic radiation, and cyclophosphamide use. 1, 2

Age-Specific Considerations

• In children: Gross hematuria is usually benign (hypercalciuria, IgA nephropathy) but still requires renal and bladder ultrasound to exclude tumors (Wilms tumor, bladder lesions) and anatomic abnormalities. 1
• In adults: The pretest probability of cancer is consistently >10% and reaches >25% in many series, mandating full urologic evaluation regardless of patient age. 1

Diagnostic Workup Algorithm

Laboratory Evaluation

• Urinalysis with microscopy: Confirm true hematuria (≥3 RBCs/HPF) and assess for dysmorphic RBCs, cellular casts, or proteinuria suggesting glomerular disease. 1, 2
• Urine culture: Obtain before antibiotics if infection suspected, but do NOT assume infection explains gross hematuria without follow-up confirmation after treatment. 2
• Serum creatinine: Assess renal function to identify potential medical renal disease. 2
• Avoid urine cytology in the initial evaluation—it is not recommended as a first-line test. 1

Imaging Strategy

• CT urography (multiphasic) is the preferred comprehensive imaging modality for adults with gross hematuria, providing optimal evaluation of the upper and lower urinary tracts. 3, 2
• Renal ultrasound with bladder imaging is appropriate for children with isolated macroscopic hematuria to detect tumors, stones, and anatomic abnormalities; the bladder must be distended for optimal assessment. 1
• MR urography is reserved for patients who cannot receive CT contrast. 3

Endoscopic Evaluation

• Cystoscopy is mandatory for all adults with gross hematuria as part of the complete urologic evaluation, even if imaging is negative. 1, 2
• In children, cystoscopy may be indicated if unexplained hematuria persists despite negative ultrasound and there is concern for bladder urothelial neoplasm. 1

Special Clinical Scenarios

When to Suspect Glomerular Disease

• Refer to nephrology if proteinuria, dysmorphic RBCs (>80%), cellular casts, or renal insufficiency are present—these suggest medical renal disease. 1, 2
• However, nephrologic referral does NOT eliminate the need for risk-based urologic evaluation, as coexistent urologic pathology may be present. 1
• Tea-colored urine suggests glomerular bleeding. 2

Benign Causes That Should Not Defer Evaluation

• Urinary tract infection: Confirm resolution of hematuria with repeat urinalysis after treatment; if hematuria persists, proceed with full urologic evaluation. 1, 2
• Benign prostatic hyperplasia (BPH): This is a common finding but should not preclude evaluation for malignancy. 3, 2
• Menstruation in women: Repeat urinalysis 48 hours after cessation; if hematuria persists, proceed with evaluation. 4

Acute Management Considerations

• Acute urinary retention from clot retention may occur with gross hematuria and can be managed with continuous bladder irrigation; emergency surgical intervention is rarely required. 5

Common Pitfalls to Avoid

• Never assume anticoagulation is the sole cause of gross hematuria—these patients have the same cancer risk and require full evaluation. 1, 3
• Do not delay referral for self-limited episodes—even transient gross hematuria warrants complete urologic assessment. 1
• Do not omit cystoscopy based on negative imaging alone, as bladder lesions may be missed. 2
• In children, do not assume benign etiology without imaging to exclude rare but serious causes like Wilms tumor. 1

Follow-Up Protocol

• If initial evaluation is negative but hematuria recurs or persists, repeat urinalysis, blood pressure monitoring, and consider repeat imaging at 6,12,24, and 36 months. 3, 2
• Reclassify patients with persistent or recurrent hematuria to higher risk categories and repeat cystoscopy and imaging. 1