Initial Management of Hematuria
Begin by classifying hematuria as gross (visible) or microscopic, as this determines malignancy risk and urgency—gross hematuria carries a 30-40% malignancy risk requiring urgent urologic evaluation, while microscopic hematuria has only a 2.6-4% risk and allows for more systematic risk stratification. 1
Immediate Classification and Risk Assessment
Gross (Macroscopic) Hematuria
- Requires urgent urologic referral regardless of whether bleeding resolves spontaneously 1
- Malignancy risk is 30-40%, including bladder cancer, renal cell carcinoma, and upper tract urothelial carcinoma 1
- Never delay evaluation even if hematuria spontaneously resolves 1
Microscopic Hematuria
- Confirm with microscopic urinalysis showing ≥3 RBCs per high-power field on two of three properly collected specimens 2
- Malignancy risk is only 2.6-4%, allowing for systematic risk stratification 1
Essential Initial Workup
History and Physical Examination
Focus on specific malignancy risk factors:
- Age and sex (men ≥60 years, women ≥60 years are higher risk) 1
- Smoking history (>30 pack-years = high risk; 10-30 pack-years = intermediate risk) 1
- Occupational exposures to aromatic amines, benzene chemicals, aristolochic acid 1
- Blood pressure measurement at every visit 2
- Exclude benign transient causes: vigorous exercise, menstruation, sexual intercourse, viral illness 1
Laboratory Testing
- Microscopic urinalysis with sediment examination to assess RBC morphology and identify red cell casts 2
- Serum creatinine to evaluate renal function 2
- Assess for proteinuria (>300 mg/day or protein/creatinine ratio >0.3 suggests glomerular disease) 1
Distinguishing Glomerular from Non-Glomerular Sources
Glomerular Origin (Requires Nephrology Referral)
- Dysmorphic RBCs (>80% of RBCs on phase-contrast microscopy) 1
- Red blood cell casts 1
- Significant proteinuria (>300 mg/day or protein/creatinine ratio >0.3) 1
- Elevated serum creatinine 1
Non-Glomerular Origin (Requires Urologic Evaluation)
Risk Stratification for Urologic Malignancy (Non-Glomerular Hematuria)
The American Urological Association provides specific criteria:
High-Risk Patients (1.3%-6.3% malignancy risk)
Intermediate-Risk Patients (0.2%-3.1% malignancy risk)
Low/Negligible Risk Patients (0%-0.4% malignancy risk)
Initial Imaging Strategy
For Gross Hematuria (Adults)
- CT urography is preferred for comprehensive upper and lower tract evaluation 2
- Renal and bladder ultrasound is an acceptable alternative if CT is contraindicated 3
- Bladder must be adequately distended during ultrasound to avoid false-negatives 3
For Microscopic Hematuria (Risk-Based)
- High and intermediate-risk patients: CT urography plus cystoscopy 2
- Low-risk patients: May defer imaging initially, proceed with surveillance 2
For Pediatric Hematuria
- Isolated microscopic hematuria without proteinuria: Imaging usually not appropriate initially 4
- Macroscopic hematuria: Renal and bladder ultrasound is first-line to exclude tumors, stones, and anatomic abnormalities 4
- Traumatic hematuria: CT with IV contrast if concerning mechanism, multiorgan injury, deceleration injury, flank pain/ecchymosis, or congenital renal abnormalities—even with only microscopic hematuria 4
Critical Pitfalls to Avoid
- Never attribute hematuria solely to anticoagulation or antiplatelet therapy—these medications do not explain hematuria and require full evaluation 1
- Do not use urine cytology or molecular markers (NMP22, BTA stat) in initial evaluation of asymptomatic microscopic hematuria 1
- Do not delay urologic referral for gross hematuria even if bleeding resolves 1
- Recognize that significant renal injuries can occur with microscopic hematuria in trauma—mechanism of injury matters more than degree of hematuria 1
- In children, isolated microscopic hematuria without trauma, infection, or concerning features rarely requires imaging 1
Follow-Up Protocol for Microscopic Hematuria
After negative initial evaluation: