Evaluation and Management of Hematuria
Immediate Triage Based on Type
All patients with gross hematuria require urgent urologic referral for cystoscopy and imaging, regardless of whether bleeding is self-limited, due to malignancy risk exceeding 30-40%. 1
Gross Hematuria (Visible Blood)
- Urgent urologic referral is mandatory even if bleeding has resolved spontaneously 1
- Malignancy risk is 30-40%, significantly higher than microscopic hematuria 1
- Do not delay referral while waiting for other test results 1
- Common pitfall: Never attribute gross hematuria solely to antiplatelet or anticoagulant medications without complete urologic evaluation 1
Microscopic Hematuria (Not Visible)
- Must first confirm true hematuria with microscopic urinalysis showing ≥3 RBCs per high-power field 2
- Dipstick positivity alone (without microscopic confirmation) should NOT trigger urologic workup, as specificity is only 65-99% 2
- If microscopy shows 0 RBCs despite positive dipstick, this is a false-positive—no further evaluation needed 2
- Malignancy risk is 2.6-5% 1, 3
Step 1: Exclude Benign Causes Before Proceeding
Before any imaging or specialist referral, systematically rule out:
- Urinary tract infection: Obtain urine culture 1
- Recent vigorous exercise or sexual activity 3
- Trauma 1
- Menstrual contamination: Consider catheterized specimen in women if clean-catch is unreliable 1
- Medications that may cause false-positive dipstick 1
Step 2: Determine If Source Is Glomerular vs. Non-Glomerular
This determines whether nephrology or urology referral is appropriate.
Glomerular Source Indicators (→ Nephrology Referral)
- Dysmorphic RBCs or red cell casts on microscopy 1
- Significant proteinuria (>500-1000 mg/24 hours) 3
- Elevated serum creatinine 1
- Hypertension with persistent hematuria 1
Non-Glomerular/Urologic Source Indicators (→ Urology Referral)
Step 3: Risk Stratification for Microscopic Hematuria
High-risk patients require complete urologic evaluation (cystoscopy + upper tract imaging) even with microscopic hematuria. 3
High-Risk Factors for Urologic Malignancy:
- Age ≥60 years 3
- Male sex 3
- Smoking history (risk increases with pack-years) 3
- Occupational exposures (dyes, chemicals, rubber) 1
- Irritative voiding symptoms without infection 3
For high-risk patients, even a single urinalysis with ≥3 RBC/HPF may warrant full evaluation without waiting for repeat testing. 3
Step 4: Laboratory Evaluation
Essential Tests for All Patients:
- Complete urinalysis with microscopic examination: Count RBCs per HPF, assess for dysmorphic RBCs, casts, WBCs, bacteria 1
- Urine culture to exclude infection 1
- Serum creatinine to assess renal function 1
Additional Considerations:
- Urine cytology: Recommended for all patients age ≥80 due to high transitional cell carcinoma risk 1, or if risk factors for carcinoma in situ or irritative voiding symptoms present 3
- Note: The American College of Physicians does NOT recommend routine urine cytology or molecular markers for initial bladder cancer screening in most cases 1
Step 5: Imaging for Non-Glomerular Hematuria
CT urography (multiphasic CT abdomen/pelvis with IV contrast) is the preferred imaging modality for comprehensive upper urinary tract evaluation. 1, 3
Imaging Alternatives:
- MR urography if CT is contraindicated 1
- Renal ultrasound with retrograde pyelography if both CT and MR are not feasible 1
Step 6: Specialist Referral Guidelines
Urology Referral Required For:
- All gross hematuria (urgent referral) 1, 4
- Microscopic hematuria in high-risk patients (age ≥60, smoking history, male sex, occupational exposures) 1, 3
- All patients age ≥80 with any hematuria 1
- Persistent microscopic hematuria after negative initial workup if new symptoms develop 3
Nephrology Referral Required For:
- Evidence of glomerular disease: proteinuria, red cell casts, or predominantly dysmorphic RBCs 1, 3
- Elevated serum creatinine suggesting renal parenchymal disease 1
- Persistent hematuria with development of hypertension or proteinuria 1
Step 7: Follow-Up for Negative Initial Evaluation
If initial urologic evaluation is negative but microscopic hematuria persists:
- Repeat urinalysis at 6,12,24, and 36 months 1
- Monitor blood pressure at each visit 1
- Consider nephrology referral if hematuria persists with new hypertension, proteinuria, or glomerular bleeding features 1
Immediate Urologic Re-evaluation Required If:
- Recurrent gross hematuria 1
- Abnormal urinary cytology 1
- New irritative voiding symptoms without infection 1
- Significant increase in degree of microscopic hematuria 3
Critical Pitfalls to Avoid
- Never delay urologic evaluation for gross hematuria, even if self-limited 1
- Never attribute hematuria to anticoagulation alone without complete evaluation 1
- Never proceed with urologic workup based on dipstick alone without microscopic confirmation of ≥3 RBCs/HPF 2
- Never assume painless hematuria is benign—it has stronger cancer association than painful hematuria 1
- Do not rely on urine dipstick specificity (only 65-99%)—always confirm microscopically 3, 2