What is the appropriate workup for an elderly male presenting with hematuria (blood in urine)?

Workup for Hematuria in an Elderly Male

An elderly male with hematuria requires immediate and complete urologic evaluation including multiphasic CT urography and cystoscopy, regardless of whether the hematuria is gross or microscopic, because age ≥60 years places him at high risk for urologic malignancy (30-40% risk with gross hematuria, 2.6-4% with microscopic hematuria). 1, 2, 3

Initial Confirmation and Classification

Confirm True Hematuria

• Verify microscopic hematuria with ≥3 RBCs per high-power field on microscopic examination of at least 2 of 3 properly collected clean-catch midstream urine specimens 1, 2, 3
• Dipstick positivity alone is insufficient (specificity only 65-99%) and must be confirmed microscopically 2, 4
• For elderly males with risk factors (age ≥60, smoking history), even a single specimen with ≥3 RBCs/HPF warrants full evaluation 4

Distinguish Gross vs. Microscopic

• Gross (macroscopic) hematuria is visible blood requiring urgent urologic referral with 30-40% malignancy risk 2, 5
• Microscopic hematuria (≥3 RBCs/HPF) carries 2.6-4% malignancy risk but still requires complete evaluation in elderly males 1, 2

Risk Stratification for Elderly Males

Elderly males (≥60 years) are automatically classified as high-risk regardless of other factors 4, 3. Additional risk factors that compound this include:

• Smoking history (>30 pack-years = highest risk; 10-30 pack-years = intermediate additional risk) 2, 4
• Occupational exposure to chemicals, dyes, benzenes, or aromatic amines 1, 2
• History of gross hematuria (even if currently microscopic) 2
• Irritative voiding symptoms without infection 1
• Prior pelvic irradiation or cyclophosphamide exposure 1

Mandatory Urologic Evaluation

Upper Tract Imaging

Multiphasic CT urography (CTU) is the gold standard imaging modality 1, 2, 4:

• Requires non-contrast phase to detect stones 1
• Contrast-enhanced phases to evaluate renal parenchyma for masses 1
• Excretory phase to visualize urothelium of upper tracts 1
• Sensitivity and specificity of 92% and 93% respectively for detecting urologic pathology 6

Check renal function (serum creatinine, eGFR, BUN) before contrast administration to assess safety of contrast studies 1

Lower Tract Evaluation

Cystoscopy is mandatory for all patients ≥35 years with hematuria 1, 4, 3:

• Detects bladder tumors (most common malignancy in hematuria cases) 2
• Evaluates for benign prostatic hyperplasia in elderly males 2
• Flexible cystoscopy preferred (less painful, equivalent diagnostic accuracy to rigid) 1
• Can be performed under local anesthesia 1

Laboratory Testing

Complete the following laboratory workup 1, 2:

• Serum creatinine, BUN, eGFR to assess renal function 1
• Complete urinalysis with microscopy examining for: 2, 4
  • Dysmorphic RBCs (>80% suggests glomerular source) 2
  • Red cell casts (pathognomonic for glomerular disease) 2
  • Proteinuria (spot protein-to-creatinine ratio; >0.2 g/g abnormal) 2
• Urine cytology for high-risk patients (elderly males with smoking history) to detect high-grade urothelial carcinoma 1, 2

Concurrent Nephrologic Evaluation

Nephrology referral is indicated if any of the following are present 1, 2:

• >80% dysmorphic RBCs suggesting glomerular bleeding 2
• Red cell casts in urinary sediment 2
• Significant proteinuria (protein-to-creatinine ratio >0.2 g/g) 2
• Elevated serum creatinine or declining renal function 2
• Hypertension with persistent hematuria 1, 2

Important: The presence of these findings does NOT eliminate the need for urologic evaluation, as both processes can coexist 1

Special Considerations for Elderly Males

Anticoagulation is NOT an Excuse

Hematuria in patients on anticoagulants or antiplatelet agents requires full urologic evaluation 1, 2:

• These medications may unmask underlying pathology but do not cause hematuria 2
• Never defer evaluation based on anticoagulation status 1

Benign Prostatic Hyperplasia

• BPH is common in elderly males and may cause hematuria 2, 5
• However, BPH does not exclude malignancy—complete evaluation still required 1
• Patients with BPH and persistent hematuria need annual urinalysis and clinical judgment for re-evaluation 1

Follow-Up Protocol if Initial Evaluation is Negative

If complete workup reveals no malignancy or significant pathology 1:

Surveillance Schedule

• Repeat urinalysis, urine cytology, and blood pressure at 6,12,24, and 36 months 1, 3
• Annual urinalysis thereafter for persistent microscopic hematuria 1
• Consider repeat complete evaluation at 3-5 years if hematuria persists 1, 3

Triggers for Immediate Re-evaluation

Urgent repeat urologic evaluation if any of the following develop 1:

• Gross hematuria (visible blood) 1
• Abnormal or suspicious urine cytology 1
• Irritative voiding symptoms without infection 1
• Substantial increase in degree of microscopic hematuria 1

When to Stop Surveillance

• If no concerning findings occur within 3 years, further urologic monitoring is not required 1
• Continue monitoring if patient remains high-risk or develops new symptoms 1

Critical Pitfalls to Avoid

Do not rely on dipstick alone—always confirm with microscopic examination showing ≥3 RBCs/HPF 2, 4

Do not assume anticoagulation explains hematuria—these patients have the same malignancy risk and require full evaluation 1, 2

Do not skip cystoscopy in elderly males—bladder cancer is the most common malignancy detected, and 99.3% of urologic malignancies in hematuria patients occur in those >35 years 1

Do not defer evaluation for "benign" causes like BPH—these can coexist with malignancy 1

Do not ignore intermittent hematuria—the degree and frequency of hematuria does not correlate with seriousness of underlying pathology 7

Gross hematuria should never be ignored even if self-limited—it carries >10% malignancy risk and requires urgent urologic referral 2, 5