What are the treatment options for hematuria (blood in urine)?

Treatment of Hematuria: A Structured Approach

The treatment of hematuria is not about treating the blood itself—it is about identifying and treating the underlying cause through systematic evaluation and appropriate specialist referral. 1

Immediate Management Based on Hematuria Type

Gross (Visible) Hematuria

All patients with gross hematuria require urgent urologic referral, even if the bleeding is painless or self-limited, as the malignancy risk exceeds 10%. 1, 2

• Refer immediately to urology for cystoscopy and upper tract imaging (multiphasic CT urography preferred) 2, 3
• Do not delay evaluation even if the patient is on anticoagulants or antiplatelet agents—these medications unmask but do not cause hematuria 1, 2
• Painless gross hematuria has a particularly strong association with malignancy compared to hematuria with flank pain (which suggests stone disease) 1

Microscopic Hematuria

First confirm the finding with microscopic urinalysis showing ≥3 RBCs per high-power field before initiating any workup. 1, 4

• A positive dipstick alone is insufficient—it has limited specificity (65-99%) and requires microscopic confirmation 3
• If confirmed and no benign cause is identified, refer to urology for cystoscopy and imaging 1, 2
• The malignancy risk with microscopic hematuria ranges from 0.5-5%, but can exceed 20% in high-risk subgroups 1

Identifying the Source: Glomerular vs. Non-Glomerular

Glomerular Source (Refer to Nephrology)

If urinary sediment shows >80% dysmorphic RBCs, red cell casts, or significant proteinuria, the source is glomerular and requires nephrology referral, not urology. 3

• Red cell casts are pathognomonic for glomerular disease 3
• Tea-colored urine suggests glomerular bleeding 1, 3
• Check for proteinuria using spot urine protein-to-creatinine ratio (normal <0.2 g/g) 3
• Obtain serum creatinine, complement levels (C3, C4), ANA, and ANCA if vasculitis suspected 3

Non-Glomerular Source (Refer to Urology)

If urinary sediment shows >80% normal RBCs without casts or significant proteinuria, pursue urologic evaluation. 3

• Complete urologic workup includes cystoscopy (mandatory) and multiphasic CT urography 3
• Flexible cystoscopy is preferred over rigid cystoscopy for patient comfort with equivalent diagnostic accuracy 3
• Do not rely on imaging alone—cystoscopy cannot be omitted even with negative imaging 2

Treatment of Identified Causes

Urinary Tract Infection

• Obtain urine culture before starting antibiotics 3
• Repeat urinalysis after treatment to confirm resolution of hematuria 3
• If hematuria persists after infection treatment, proceed with full urologic evaluation 2, 3

Urolithiasis (Kidney Stones)

• Symptomatic stones with flank pain typically require urologic management 1, 3
• CT urography identifies stones and guides treatment planning 3, 5

Benign Prostatic Hyperplasia (BPH)

• Common cause in older men, but malignancy must still be excluded 3
• Treat BPH medically, but complete urologic evaluation is still required 3

Malignancy

• Bladder cancer, renal cell carcinoma, and upper tract urothelial carcinoma require immediate urologic oncology management 3, 5
• Early detection through prompt evaluation improves prognosis 5

Risk Stratification for Microscopic Hematuria

High-risk patients require full urologic evaluation after even one positive specimen: 3

• Age: Men ≥60 years, women ≥60 years 3
• Smoking history >30 pack-years 3
• Occupational exposure to chemicals/dyes (benzenes, aromatic amines) 3
• History of gross hematuria 3
• History of urologic disorders 3

Intermediate-risk patients: 3

• Men 40-59 years 3
• Smoking history 10-30 pack-years 3

Low-risk patients may have less extensive workup if a benign cause is identified, but this requires clinical judgment. 3

Follow-Up Protocol for Negative Initial Evaluation

If the complete urologic workup is negative but microscopic hematuria persists, implement structured surveillance: 3

• Repeat urinalysis at 6,12,24, and 36 months 3
• Monitor blood pressure at each visit 3
• Consider voided urine cytology in high-risk patients 3

Immediate re-evaluation is required if: 3

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

Critical Pitfalls to Avoid

• Never attribute hematuria solely to anticoagulation—full evaluation is mandatory regardless of medication use 1, 2
• Never delay evaluation of gross hematuria, even if self-limited or painless 1, 2
• Never omit cystoscopy based on negative imaging alone 2
• Never use urinary cytology or molecular markers in the initial evaluation—these are not recommended 1
• Never screen asymptomatic adults with urinalysis for cancer detection 1
• Never assume infection explains gross hematuria without follow-up confirmation after treatment 2

Special Populations

Elderly Patients

• Malignancy risk is significantly elevated in patients >60 years 3
• Lower threshold for complete urologic evaluation 3

Children

• Glomerulonephritis and congenital anomalies are more common causes 3
• Ultrasound is preferred over CT to avoid radiation 3
• Children with isolated microscopic hematuria without proteinuria or dysmorphic RBCs typically do not require imaging 3

Patients with Chronic Kidney Disease

• eGFR <30 mL/min/1.73 m² requires nephrology referral, not urology 2
• Persistent proteinuria with hematuria suggests glomerular disease requiring nephrology evaluation 3