What should be done when someone presents with frank hematuria?

Management of Frank (Gross) Hematuria

All patients with frank hematuria require urgent urologic referral for cystoscopy and imaging, even if the bleeding is self-limited, due to the consistently high risk of underlying malignancy (>10% and up to 25-40% in some series). 1, 2

Immediate Actions

Do Not Delay Referral

• Refer urgently to urology regardless of whether the hematuria has resolved spontaneously 1, 2
• The self-limited nature of gross hematuria provides false reassurance but does not reduce cancer risk 1
• Do not wait for other test results before making the referral 2

Continue Evaluation Despite Anticoagulation

• Pursue full evaluation even if the patient is taking antiplatelet or anticoagulant medications 1, 2
• Do not attribute the bleeding solely to these medications without complete workup 1, 3

Clinical Context Matters

Painless vs. Painful Hematuria

• Painless gross hematuria has a stronger association with malignancy 1, 2
• Hematuria with flank pain or renal colic suggests urinary stone disease, but concurrent pathology must still be excluded 1, 4

Initial Laboratory Assessment

• Obtain microscopic urinalysis to confirm true hematuria (≥3 RBCs per high-power field) 1, 3
• Check serum creatinine to assess renal function 2
• Obtain urine culture if infection is suspected based on symptoms or urinalysis findings 3
• Do not obtain urine cytology or molecular markers in the initial evaluation - this is not recommended by the American College of Physicians 1, 2

Urologic Evaluation Components

The urologist will perform:

• Cystoscopy to exclude bladder cancer 2
• CT urography (CT abdomen/pelvis with IV contrast) as the preferred imaging modality for comprehensive evaluation of the upper urinary tract 2
• MR urography if CT is contraindicated 2

Special Considerations

High-Risk Features Requiring Attention

• Age >40 years 3
• Smoking history 3
• Occupational exposure to chemicals, dyes, benzenes, or aromatic amines 3
• History of pelvic irradiation 3

If Infection is Confirmed

• Treat the urinary tract infection appropriately 3
• Repeat urinalysis 6 weeks after completing antibiotic treatment to confirm resolution of hematuria 3
• If hematuria persists after infection treatment, proceed with full urologic evaluation 3

Common Pitfalls to Avoid

• Never assume resolution means no further workup is needed - approximately 19.8% of patients referred for microscopic hematuria report a history of self-limited gross hematuria when specifically asked, and this carries a 7.2-fold increased odds of urologic cancer 1, 3
• Do not delay evaluation while treating presumed benign causes 2
• Do not skip urologic referral in elderly patients even with other comorbidities - the cancer risk remains substantial 2

If Initial Urologic Workup is Negative

• Repeat urinalysis at 6,12,24, and 36 months 2, 3
• Monitor blood pressure at each visit 2, 3
• Consider nephrology referral if hematuria persists with development of hypertension, proteinuria, or evidence of glomerular bleeding 2, 3
• Immediate urologic reevaluation is necessary if: recurrent gross hematuria, abnormal urinary cytology, or irritative voiding symptoms without infection 2