What is the initial workup for a patient presenting with gross hematuria?

Workup for Gross Hematuria

All patients with gross hematuria require urgent urologic evaluation with cystoscopy and upper tract imaging (CT urography preferred), as the malignancy risk is 30-40% regardless of other risk factors. 1, 2

Initial Clinical Assessment

Perform a focused history and physical examination targeting:

• Detailed smoking history with pack-year quantification (>30 pack-years = high risk for urothelial malignancy) 1
• Occupational/environmental exposures to chemicals, dyes, or carcinogens associated with bladder cancer 1
• Family history of urologic malignancies and genetic risk factors 1
• Blood pressure measurement to assess for renal parenchymal disease 1
• Age and sex (men >60 years and women >60 years have higher malignancy risk) 1
• Irritative voiding symptoms, history of pelvic irradiation, chronic UTI, or indwelling catheters 1

Laboratory Evaluation

• Urinalysis with microscopy to confirm true hematuria (not myoglobinuria or hemoglobinuria) 2
• Serum creatinine to assess renal function and identify potential medical renal disease 1, 3
• Urine culture if infection is suspected (obtain before antibiotics if possible) 2
• Urine cytology may be considered, particularly in high-risk patients 2

Determining Glomerular vs. Non-Glomerular Source

Examine urinary sediment for:

• Dysmorphic RBCs >80% and red cell casts suggest glomerular bleeding (tea-colored urine is characteristic) 1, 2
• Significant proteinuria indicates renal parenchymal disease requiring nephrology referral 2, 3
• Normal RBCs >80% without casts or proteinuria suggests urologic source 2

Imaging and Endoscopic Evaluation

For non-glomerular gross hematuria (the vast majority):

• CT urography (multiphasic) is the preferred imaging modality for upper tract evaluation 1, 3
• Cystoscopy is mandatory for lower tract evaluation to exclude bladder malignancy 1, 2
• Both procedures should be performed urgently, even if bleeding is self-limited 2

For suspected glomerular source:

• Refer to nephrology for evaluation of primary renal disease, which may include renal biopsy 3
• Upper tract imaging may still be warranted depending on clinical context 1

Critical Pitfalls to Avoid

• Never dismiss gross hematuria as benign, even in patients on anticoagulation—these medications unmask underlying pathology but do not cause hematuria 2
• Do not delay evaluation for self-limited episodes; 30-40% harbor malignancy 1, 2
• Exclude urinary tract infection before attributing hematuria to infection alone, as malignancy can coexist 2
• Do not accept vigorous exercise or menstruation as explanations for gross hematuria without complete evaluation 2

Special Considerations

• Smoking cessation counseling should be provided at initial visit with referral to evidence-based cessation programs 1
• Patients with BPH still require full evaluation, as this does not exclude concurrent malignancy 2, 4
• Renal parenchymal disease is the most common benign nephrogenic cause but must be distinguished from malignancy 1