What is the appropriate evaluation and treatment for hematuria (presence of blood in the urine)?

Evaluation and Management of Hematuria

Initial Confirmation and Triage

All patients with gross hematuria require immediate urologic referral regardless of whether it is self-limited, while microscopic hematuria must first be confirmed with microscopic urinalysis showing ≥3 RBCs per high-power field before initiating any further workup. 1, 2

• Do not rely on dipstick testing alone—confirm all heme-positive dipstick results with microscopic examination demonstrating ≥3 erythrocytes per high-powered field 1, 2
• Specifically ask all patients about any history of gross hematuria during routine review of systems, as visible blood in urine significantly increases cancer risk (odds ratio 7.2) and is often underreported 1, 3
• Gross hematuria carries >10% risk of malignancy and mandates prompt urologic evaluation even if self-limited 1, 4

Exclude Benign Transient Causes

Before proceeding with extensive evaluation, rule out reversible causes and repeat urinalysis 48 hours after cessation of the potential trigger 2, 3:

• Menstruation, vigorous exercise, sexual activity, trauma 2, 3
• Viral illness 2, 3
• Urinary tract infection—obtain urine culture if suspected, treat appropriately, and repeat urinalysis 6 weeks after treatment to confirm resolution 3
• Medications 2

Critical pitfall: Do not attribute hematuria solely to antiplatelet or anticoagulant therapy without complete evaluation—these patients still require full workup 1, 3

Risk Stratification for Urologic Malignancy

High-risk features that mandate complete urologic evaluation include 2, 3, 5:

• Age ≥40 years (some guidelines use ≥60 years as highest risk) 2, 3, 5
• Smoking history (risk increases with pack-years) 2, 3, 5
• Male sex 5
• Occupational exposure to chemicals/dyes (benzenes or aromatic amines) 2, 3
• History of pelvic irradiation 2, 3
• Irritative voiding symptoms 2, 3
• History of gross hematuria 2, 3
• Analgesic abuse 2, 3

Distinguish Glomerular vs. Non-Glomerular Source

Perform comprehensive urinalysis with sediment examination to determine the origin 2, 3, 5:

Glomerular indicators (nephrology referral needed):

• Dysmorphic RBCs >80% 2, 3, 5
• Red cell casts 2, 3, 5
• Significant proteinuria >500 mg/24 hours 2, 3, 5
• Elevated serum creatinine 2, 3

Non-glomerular indicators (urologic evaluation needed):

• Normal-appearing RBCs without casts 5
• Absence of significant proteinuria 5
• Normal renal function 5

Complete Urologic Evaluation for Non-Glomerular Hematuria

For patients with confirmed microscopic hematuria without benign cause or glomerular source, refer to urology for cystoscopy and imaging 1, 2, 3:

Upper Tract Imaging

• CT urography is the preferred imaging modality for comprehensive evaluation of the upper urinary tract 2, 5
• CT urography identifies hydronephrosis, urinary calculi, and renal/ureteral lesions 5
• Important consideration: Younger patients have lowest pretest probability of upper tract cancer but highest potential carcinogenesis risk from CT radiation—risk-stratification algorithms can reduce unnecessary CT testing in lower-risk subgroups 1

Cystoscopy

• Mandatory in all patients ≥40 years of age 2
• Required in patients <40 years with risk factors for bladder cancer (smoking, occupational exposures, irritative voiding symptoms, history of gross hematuria) 2
• Evaluates for bladder masses, urethral stricture disease, and benign prostatic hyperplasia 5

Urine Cytology

• Do not obtain urinary cytology or other urine-based molecular markers in the initial evaluation of hematuria 1
• Consider only if risk factors for carcinoma in situ or irritative voiding symptoms are present 5
• Recommended in all patients with risk factors for transitional cell carcinoma 2

Follow-Up Protocol for Persistent Hematuria After Negative Workup

Repeat urinalysis at 6,12,24, and 36 months for patients with persistent hematuria after negative initial evaluation 2, 3:

• Monitor blood pressure at each follow-up visit 2, 3
• Refer to nephrology if hematuria persists with development of hypertension, proteinuria (>500 mg/24 hours), or evidence of glomerular bleeding (red cell casts, dysmorphic RBCs) 2, 3
• Further workup warranted if patient develops gross hematuria, significant increase in degree of microscopic hematuria, or new urologic symptoms 5

What NOT to Do

• Do not use screening urinalysis for cancer detection in asymptomatic adults 1
• Do not delay evaluation in high-risk patients—early detection of urologic malignancy significantly impacts mortality and morbidity 5
• Do not skip evaluation in patients on anticoagulation—pursue full workup regardless of antiplatelet or anticoagulant therapy 1, 3
• Do not obtain urine cytology as part of initial evaluation 1