What is the initial workup for a patient presenting with hematuria (blood in urine) and pelvic pain?

Initial Workup for Hematuria and Pelvic Pain

The initial workup must include urinalysis with microscopy to confirm true hematuria (≥3 RBCs/HPF), urine culture to exclude infection, serum creatinine to assess renal function, and urgent imaging with CT urography plus cystoscopy if gross hematuria is present or if the patient has high-risk features for malignancy. 1, 2, 3

Immediate Clinical Assessment

Confirm True Hematuria

• Verify microscopic hematuria with ≥3 red blood cells per high-power field on properly collected clean-catch midstream specimen 1, 2
• Dipstick positivity alone has only 65-99% specificity and requires microscopic confirmation before proceeding with extensive workup 2
• Distinguish true hematuria from myoglobinuria or hemoglobinuria 3

Critical History Elements

• Quantify smoking history in pack-years: >30 pack-years represents high risk for urothelial malignancy 2, 3
• Document occupational exposures to chemicals, dyes, benzenes, or aromatic amines associated with bladder cancer 1, 3
• Characterize the pelvic pain: location, character, severity, relationship to voiding, and duration (symptoms should be present for at least 6 weeks to consider interstitial cystitis/bladder pain syndrome) 1
• Assess for irritative voiding symptoms (frequency, urgency, dysuria) which may indicate high-risk conditions including malignancy or IC/BPS 1, 2
• Document gross vs. microscopic hematuria: gross hematuria carries 30-40% malignancy risk regardless of other factors 2, 3
• Recent vigorous exercise, menstruation, or urologic instrumentation as potential benign causes 2, 4
• History of pelvic irradiation, chronic UTI, indwelling catheters, or pelvic trauma 3

Physical Examination Priorities

• Blood pressure measurement to assess for renal parenchymal disease 3
• Brief neurological exam to rule out occult neurologic problems 1
• Evaluation for incomplete bladder emptying to rule out occult retention 1
• Pelvic examination in women; note relationship of pain to menstruation 1
• Assessment for blood at urethral meatus, especially with pelvic fractures (50% incidence of genitourinary injury) 1

Mandatory Laboratory Evaluation

Core Laboratory Tests

• Urinalysis with microscopy to confirm hematuria and examine for dysmorphic RBCs, red cell casts, and proteinuria 1, 2, 3
• Urine culture (preferably before antibiotics) to exclude urinary tract infection, even with negative dipstick, as lower bacterial levels may be clinically significant 1, 2, 3
• Serum creatinine, BUN, and complete metabolic panel to assess renal function and identify medical renal disease 2, 3
• Complete blood count to evaluate for anemia from blood loss and underlying kidney disease 2

Distinguishing Glomerular from Non-Glomerular Sources

• Glomerular indicators: dysmorphic RBCs >80%, red cell casts (pathognomonic), significant proteinuria (protein-to-creatinine ratio >0.2), tea-colored urine 2, 4, 3
• Non-glomerular indicators: normal RBCs >80%, absence of proteinuria or casts, bright red blood 2, 4, 3
• If glomerular source suspected: check complement levels (C3, C4), ANA, ANCA, and obtain nephrology referral 2

Risk Stratification for Imaging and Cystoscopy

High-Risk Features Requiring Urgent Full Evaluation

• Any gross hematuria (30-40% malignancy risk) 2, 3
• Age: men ≥60 years, women ≥60 years 2
• Smoking history >30 pack-years 2
• Occupational chemical/dye exposure 1, 3
• Irritative voiding symptoms without infection 2
• History of pelvic irradiation or cyclophosphamide exposure 1

Imaging Strategy

For Non-Glomerular Hematuria with Pelvic Pain:

• Multiphasic CT urography (without and with IV contrast) is the imaging procedure of choice, including sufficient phases to evaluate renal parenchyma for masses and an excretory phase to evaluate upper tract urothelium 1, 2, 3
• CT urography has the highest sensitivity and specificity for detecting renal cell carcinoma, transitional cell carcinoma, and urolithiasis 1, 2
• If renal injury suspected from trauma: delayed scans should be obtained to evaluate for collecting system disruption 1
• If pelvic fracture present with gross hematuria: CT cystography (CT pelvis after retrograde bladder distention with contrast) to evaluate for bladder rupture 1

Alternative Imaging (Less Optimal):

• Renal ultrasound combined with intravenous urography is widely used but does not reliably produce diagnostic certainty and presents significant risk for missed diagnoses 1
• Ultrasound alone is insufficient for comprehensive upper tract evaluation 2

Cystoscopy Indications

Mandatory cystoscopy for:

• All patients with gross hematuria to exclude bladder malignancy 2, 3
• All patients with risk factors for urinary tract malignancies (irritative voiding symptoms, tobacco use, chemical exposures) regardless of age 1
• Suspected Hunner lesions in patients with IC/BPS symptoms, as this is the only reliable way to diagnose these lesions and early diagnosis allows targeted treatment without requiring failure of other therapies first 1
• Flexible cystoscopy causes less pain and has equivalent or superior diagnostic accuracy compared to rigid cystoscopy 2

Special Considerations for Pelvic Pain

Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS)

• Clinical diagnosis requires: symptoms present for at least 6 weeks with documented negative urine cultures, bladder/pelvic pain and pressure/discomfort associated with urinary frequency and strong urge to void 1
• Document: number of voids per day, sensation of constant urge, location/character/severity of pain, dyspareunia, dysuria 1
• Baseline voiding log (at minimum one day) to establish low-volume frequency voiding pattern characteristic of IC/BPS 1
• Proper hematuria workup should be performed in IC/BPS patients with unevaluated hematuria, and considered in those with tobacco exposure given high bladder cancer risk in smokers 1
• Hematuria occurs in up to 41% of IC/BPS patients but evaluation rarely reveals life-threatening conditions 5

Urolithiasis Considerations

• Painful hematuria with flank pain suggests urolithiasis 2, 4
• CT without contrast is highly sensitive for stone detection 1
• Ultrasound has limited sensitivity (75% for all stones, only 38% for ureteral stones) 1

Critical Pitfalls to Avoid

• Never dismiss hematuria in patients on anticoagulation or antiplatelet therapy: these medications unmask underlying pathology but do not cause hematuria and should not defer evaluation 1, 2, 3
• Never accept self-limited gross hematuria as benign: 30-40% harbor malignancy and require complete evaluation 2, 3
• Never attribute hematuria to BPH without complete evaluation: malignancy can coexist 3
• Never delay evaluation for urinary tract infection: exclude infection but recognize malignancy can coexist 3
• Blood at urethral meatus with pelvic fracture: perform retrograde urethrography before catheter placement 1

Follow-Up Protocol if Initial Workup Negative

• Repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring at each visit 2
• Immediate re-evaluation warranted if: gross hematuria develops, significant increase in microscopic hematuria, new urologic symptoms, or development of hypertension/proteinuria/glomerular bleeding 2
• Nephrology referral indicated for: persistent significant proteinuria, red cell casts or >80% dysmorphic RBCs, elevated/declining renal function, hypertension with hematuria and proteinuria 2