What is the evaluation and management approach for a patient presenting with hematuria?

Evaluation and Management of Hematuria

Initial Confirmation and Classification

All dipstick-positive hematuria must be confirmed with microscopic urinalysis showing ≥3 RBCs per high-power field on at least two of three properly collected clean-catch midstream specimens before initiating any workup. 1, 2

• Dipstick testing has limited specificity (65-99%) and can yield false positives from myoglobinuria, hemoglobinuria, or menstrual contamination 3
• Findings of 0-2 RBCs/HPF fall within normal range and require no urologic evaluation 1
• Gross hematuria requires immediate urologic referral after a single episode, even if self-limited, due to 30-40% malignancy risk 1, 2

Exclude Benign and Transient Causes

Before proceeding with extensive evaluation, systematically rule out:

• Urinary tract infection: Obtain urine culture before antibiotics, treat appropriately, and repeat urinalysis 6 weeks post-treatment to confirm resolution 2, 3
• Menstruation: Repeat urinalysis 48 hours after cessation 3
• Vigorous exercise or recent sexual activity: Repeat urinalysis 48 hours later 1, 3
• Medications: Note that anticoagulation/antiplatelet therapy does NOT explain hematuria and should never defer evaluation, as these agents may unmask underlying pathology 1, 2

Risk Stratification for Malignancy

The AUA/SUFU guidelines stratify patients into three risk categories based on age, smoking history, and degree of hematuria 1, 2:

Low Risk:

• Women <50 years or men <40 years
• Never smoker or <10 pack-years
• 3-10 RBCs/HPF
• No additional risk factors 1

Intermediate Risk:

• Women 50-59 years or men 40-59 years
• 10-30 pack-years smoking history
• 11-25 RBCs/HPF 1

High Risk:

• Age ≥60 years (either sex)

• 30 pack-years smoking history

• 25 RBCs/HPF

• History of gross hematuria
• Occupational exposure to benzenes or aromatic amines
• History of pelvic irradiation 1, 2, 3

Determine Glomerular vs. Non-Glomerular Source

Examine urinary sediment for dysmorphic RBCs and red cell casts to differentiate glomerular from urologic causes 1, 3:

Glomerular indicators (nephrology referral indicated):

• 80% dysmorphic RBCs 1, 3

• Red cell casts (pathognomonic for glomerular disease) 1, 3
• Significant proteinuria (protein-to-creatinine ratio >0.2 g/g or >500 mg/24 hours) 1, 3
• Elevated serum creatinine or declining renal function 1
• Tea-colored urine 1

Non-glomerular indicators (urologic evaluation indicated):

• 80% normal-appearing RBCs 1

• Absence of proteinuria or minimal proteinuria 1
• Normal renal function 1

Complete Urologic Evaluation for Non-Glomerular Hematuria

For intermediate and high-risk patients, or those with persistent hematuria without benign explanation, perform both upper and lower tract evaluation 2, 3:

Upper Tract Imaging:

• Multiphasic CT urography is the preferred modality for detecting renal cell carcinoma, transitional cell carcinoma, and urolithiasis 2, 3
• Renal ultrasound is insufficient as sole imaging in at-risk patients 1

Lower Tract Evaluation:

• Cystoscopy is mandatory for all patients ≥40 years with microscopic hematuria and all patients with gross hematuria, regardless of imaging results 2, 3
• Flexible cystoscopy is preferred due to equivalent diagnostic accuracy with less discomfort 2
• Delays in bladder cancer diagnosis increase mortality by 34% 2

Adjunctive Testing:

• Voided urine cytology for high-risk patients (age ≥60, heavy smoking history) to detect carcinoma in situ 2, 3
• Serum creatinine to assess renal function 2, 3

Management Based on Risk Category

High-Risk Patients:

• Cystoscopy AND CT urography required 1, 2
• Urine cytology recommended 2

Intermediate-Risk Patients:

• Cystoscopy with urinary tract imaging through shared decision-making 1, 2

Low-Risk Patients:

• May undergo repeat urinalysis in 6 months OR proceed with evaluation based on patient preference and clinical judgment 1, 3
• If benign cause identified and no risk factors present, extensive imaging may not be required 1

Nephrology Referral Criteria

Refer to nephrology when glomerular disease is suspected 1, 3:

• Proteinuria with protein-to-creatinine ratio >0.2 g/g on three specimens 1

• 80% dysmorphic RBCs or red cell casts 1, 3

• Elevated creatinine or declining renal function 1
• Hypertension with concurrent hematuria and proteinuria 1, 3

Additional workup for suspected glomerular disease:

• Complete metabolic panel (creatinine, BUN, albumin, total protein) 1
• Complement levels (C3, C4) for post-infectious glomerulonephritis or lupus nephritis 1
• ANA and ANCA if vasculitis suspected 1
• Renal ultrasound to evaluate kidney size and echogenicity 1

Follow-Up Protocol for Negative Initial Evaluation

If complete evaluation is negative but hematuria persists, implement structured surveillance 1, 3:

• Repeat urinalysis at 6,12,24, and 36 months 1, 3
• Monitor blood pressure at each visit 1, 3
• Consider repeat cystoscopy and imaging within 3-5 years for persistent or recurrent hematuria, particularly in high-risk populations 3

Immediate re-evaluation is warranted if 1, 3:

• Gross hematuria develops 1, 3
• Significant increase in degree of microscopic hematuria occurs 1, 3
• New urologic symptoms appear (irritative voiding, flank pain, dysuria) 1, 3
• Hypertension, proteinuria, or evidence of glomerular bleeding develops 1, 3

Critical Pitfalls to Avoid

• Never attribute hematuria solely to anticoagulation without full evaluation—these medications unmask rather than cause bleeding 1, 2, 3
• Never defer evaluation in elderly patients (≥60 years) regardless of other factors—age alone places them at high risk 2, 3
• Never skip cystoscopy in patients ≥40 years even if imaging is negative—bladder lesions may not be visible on CT 2, 3
• Never accept dipstick results alone—microscopic confirmation of ≥3 RBCs/HPF is mandatory 1, 2
• Never assume UTI explains hematuria without confirming resolution 6 weeks post-treatment—persistent hematuria requires full evaluation 2, 3
• Gross hematuria has significantly higher malignancy rates (30-40%) compared to microscopic hematuria (2.6-4%), but both require evaluation in at-risk patients 1, 4