What should be done for an elderly male with hematuria (blood in urine)?

Urgent Urologic Referral Required for Gross Hematuria

An elderly male with visible blood in underwear (gross hematuria) requires immediate urologic referral for cystoscopy and upper tract imaging, regardless of whether the bleeding has stopped, as the risk of underlying malignancy exceeds 10%. 1, 2

Immediate Actions

• Refer urgently to urology - do not delay evaluation even if the bleeding resolves spontaneously, as gross hematuria carries a 30-40% risk of malignancy in this age group 1, 2
• Confirm true hematuria with microscopic urinalysis showing ≥3 red blood cells per high-power field, though gross hematuria visible to the naked eye is already diagnostic 1
• Obtain urine culture to exclude urinary tract infection as a contributing factor, though infection does not explain away the need for full evaluation 1, 2

Essential Diagnostic Workup

The urologist will perform:

• Cystoscopy - mandatory to visualize the bladder mucosa and exclude bladder cancer, which is the most frequently diagnosed malignancy in hematuria cases 3, 1, 2
• CT urography (multiphasic) - preferred imaging modality to detect renal cell carcinoma, transitional cell carcinoma, and urolithiasis throughout the upper urinary tract 1, 2
• Urine cytology - recommended given the patient's high-risk status (elderly male with gross hematuria) to detect urothelial cancers 1, 2

Risk Stratification

This patient is automatically high-risk based on:

• Gross hematuria alone (30-40% malignancy risk vs. 2.6-4% for microscopic) 2
• Elderly age (likely >60 years based on "elderly male" descriptor) 1
• Male gender (higher malignancy risk than females) 1

Additional risk factors to document include:

• Smoking history (>30 pack-years = high risk) 1, 2
• Occupational exposure to benzenes or aromatic amines (dyes, chemicals) 1, 2
• History of irritative voiding symptoms 1

Critical Pitfalls to Avoid

• Never attribute gross hematuria solely to anticoagulation or antiplatelet therapy - these medications may unmask underlying pathology but do not cause hematuria; full evaluation is still mandatory 1, 2
• Do not wait for additional test results before making the urologic referral - the presence of gross hematuria alone mandates urgent specialist evaluation 2
• Do not assume resolution of bleeding means resolution of risk - even self-limited gross hematuria requires complete evaluation 1, 2

Laboratory Assessment While Awaiting Urology

• Serum creatinine to assess renal function 1, 2
• Complete urinalysis with microscopy to assess for dysmorphic RBCs (>80% suggests glomerular source), red cell casts, or significant proteinuria 1, 2
• Urine culture (preferably before any antibiotics if infection suspected) 2

Nephrology Referral Considerations

Consider concurrent nephrology referral if any of the following are present:

• Dysmorphic RBCs >80% with red cell casts (pathognomonic for glomerular disease) 1
• Significant proteinuria >500 mg/24 hours 1
• Elevated serum creatinine or declining renal function 1
• Hypertension with hematuria 1

However, urologic evaluation takes priority and should not be delayed even if glomerular disease is suspected 1

Follow-Up Protocol

If initial urologic workup is negative:

• Repeat urinalysis at 6,12,24, and 36 months 3, 1
• Monitor blood pressure at each visit 3, 1
• Consider comprehensive re-evaluation in 3-5 years if hematuria persists or recurs 1
• Immediate re-evaluation if gross hematuria recurs, significant increase in microscopic hematuria occurs, or new urologic symptoms develop 1