When to Refer a Patient with Abnormal Urinalysis to a Urologist
Refer immediately to urology for any patient with gross hematuria, even if self-limited, as the malignancy risk exceeds 10%. 1, 2
Immediate Urologic Referral Required
Hematuria-Related Indications:
- Any episode of gross (visible) hematuria requires urgent urologic evaluation regardless of whether it resolves spontaneously, as cancer risk ranges from 10-40%. 1, 2
- Microscopic hematuria (≥3 RBCs/HPF) without identifiable benign cause after initial workup warrants urology referral for cystoscopy and imaging. 1
- Do not delay referral based on anticoagulant or antiplatelet use—these medications unmask but do not cause hematuria. 1, 2
- Hematuria accompanied by abnormal digital rectal exam suspicious for prostate cancer. 3
Other Urinalysis Abnormalities Requiring Referral:
- Non-infectious hematuria detected on urinalysis (after UTI excluded). 4
- Elevated post-void residual with severe obstruction (Qmax <10 mL/second). 3
- Palpable bladder on examination. 3
Conditional Referral Based on Clinical Context
Overactive Bladder/Urinary Symptoms:
- Complex OAB presentations with neurologic disease or other genitourinary conditions affecting bladder function. 4
- Treatment failure after appropriate pharmacologic management. 4, 3
- Persistent bothersome symptoms despite first-line therapy. 3
Chronic Kidney Disease:
- Continuously increasing urinary albumin and/or continuously decreasing eGFR. 4
- eGFR <30 mL/min/1.73 m² (refer to nephrology, not urology). 4
- Uncertainty about CKD etiology with rapidly increasing albuminuria or active urinary sediment (nephrology referral). 4
Initial Workup Before Referral
For Hematuria:
- Confirm with microscopic urinalysis showing ≥3 RBCs/HPF. 1
- Obtain urine culture to exclude infection, but do not assume infection explains gross hematuria without follow-up confirmation. 2
- Check serum creatinine to assess renal function. 1, 2
- Do not obtain urinary cytology or urine-based molecular markers in initial evaluation. 1
For Urinary Symptoms:
- Perform urinalysis to rule out UTI and hematuria. 4
- Consider post-void residual assessment and bladder diary at clinician's discretion. 4
- Review medications that may exacerbate symptoms (anticholinergics, alpha-agonists, opioids). 3
Critical Pitfalls to Avoid
- Never attribute hematuria solely to anticoagulation—full urologic evaluation is mandatory. 1, 2
- Never delay evaluation of gross hematuria even if painless or self-limited. 2
- Do not omit cystoscopy based on negative imaging alone for hematuria evaluation. 2
- Do not assume urinary symptoms are solely medication-related without excluding structural or malignant causes. 4, 3