What is the initial workup for a 22-year-old male presenting with gross hematuria?

Workup for Gross Hematuria in a 22-Year-Old Male

A 22-year-old male with gross hematuria requires urgent urologic evaluation with renal and bladder ultrasound as first-line imaging, urine culture, urinalysis with microscopy, and serum creatinine, with cystoscopy reserved only if imaging is abnormal or hematuria persists—this age group has a very low malignancy risk and most cases are due to benign causes like infection, urethral bleeding, or congenital anomalies. 1, 2

Initial Clinical Assessment

History must specifically address:

• Recent vigorous exercise or trauma (common benign causes in young males) 3, 4
• Swimming in freshwater lakes/rivers in endemic areas (Schistosomiasis can present years later) 5
• Dysuria, frequency, urgency, or fever suggesting urinary tract infection 1, 6
• Flank pain suggesting urolithiasis 4, 6
• Family history of kidney disease, hearing loss (Alport syndrome), or polycystic kidney disease 1, 4
• Smoking history and occupational chemical exposures (though malignancy risk is <1% at age 22) 3

Physical examination should include:

• Blood pressure measurement to screen for renal parenchymal disease 1, 3
• Abdominal examination for masses or costovertebral angle tenderness 6
• Genital examination in uncircumcised males to exclude meatal stenosis or urethral pathology 1, 2

Laboratory Evaluation

Obtain the following tests immediately:

• Urinalysis with microscopy to confirm true hematuria (≥3 RBCs/HPF) and assess for dysmorphic RBCs, red cell casts, or proteinuria 3, 4
• Urine culture before any antibiotics if infection suspected 3, 4
• Serum creatinine to assess renal function 1, 3

Distinguishing glomerular from non-glomerular sources:

• Dysmorphic RBCs >80%, red cell casts, or significant proteinuria indicate glomerular disease requiring nephrology referral 3, 7, 4
• Normal RBCs >80% without casts or proteinuria suggests urologic source 3, 7
• Tea-colored urine suggests glomerular bleeding 1, 4

Imaging Strategy for Young Males

The critical difference from older adults: CT urography is NOT first-line in this age group due to radiation exposure and extremely low malignancy risk. 1

Renal and bladder ultrasound is the appropriate initial imaging modality to evaluate for:

• Urolithiasis (common cause in young males) 1, 6
• Congenital urologic anomalies (present in 13% of pediatric/young adult gross hematuria cases) 2
• Hydronephrosis or structural abnormalities 1
• Bladder masses (rare but detectable on ultrasound) 1
• Nutcracker syndrome (left renal vein compression) 1

The bladder must be adequately distended during ultrasound examination for optimal visualization. 1

Role of Cystoscopy in Young Males

Cystoscopy is NOT routinely indicated as initial evaluation in males under 40 years without risk factors for bladder cancer. 1

Defer initial cystoscopy but perform urine cytology if:

• Patient is under 40 years old 1
• No smoking history or occupational exposures 1
• Ultrasound reveals no abnormalities 1

Cystoscopy IS indicated if:

• Ultrasound findings are abnormal or ambiguous 1, 2
• Hematuria persists despite negative initial workup 1, 2
• Irritative voiding symptoms develop without infection 1, 3
• Urine cytology shows malignant or atypical cells 1

Common Etiologies in This Age Group

Benign causes account for the vast majority of cases in 22-year-old males: 2

• Benign urethrorrhagia (19% of young males with gross hematuria) 2
• Urinary tract infection (14% of cases) 2
• Trauma (14% of cases) 2
• Congenital urologic anomalies (13% of cases, including vesicoureteral reflux, ureteropelvic junction obstruction) 2
• Urolithiasis (5% of cases, often associated with hypercalciuria) 1, 2
• Idiopathic (34% of cases—no cause found even after complete evaluation) 2

Malignancy is exceedingly rare: Only 3 cases of low-grade bladder transitional cell carcinoma and 1 Wilms tumor were found among 342 pediatric/young adult patients in a 10-year review. 2

Follow-Up Protocol

If initial workup (ultrasound, urinalysis, culture, creatinine) is negative:

• Repeat urinalysis at 6,12,24, and 36 months 1
• Monitor blood pressure at each visit 1
• Consider urine cytology at follow-up visits 1

Immediate re-evaluation with cystoscopy and possible CT urography if:

• Gross hematuria recurs 1, 3
• Irritative voiding symptoms develop without infection 1, 3
• Abnormal urine cytology 1
• Development of hypertension, proteinuria, or glomerular bleeding indicators 1, 4

Nephrology referral if:

• Persistent hematuria with proteinuria, hypertension, or elevated creatinine 1, 4
• Dysmorphic RBCs >80% or red cell casts present 3, 4

Critical Pitfalls to Avoid

Do not dismiss hematuria even if:

• Patient recently exercised vigorously (must still confirm resolution with repeat urinalysis 48 hours after cessation) 1, 3
• Patient takes medications like NSAIDs or supplements (these unmask but don't cause hematuria) 3, 4
• Initial ultrasound is normal (34% of young patients have idiopathic hematuria requiring surveillance) 2

Do not order CT urography as first-line imaging in a 22-year-old without high-risk features—this exposes the patient to unnecessary radiation when ultrasound is appropriate and diagnostic. 1

Do not perform routine cystoscopy in young males without risk factors or abnormal imaging—the yield is extremely low and the procedure is invasive. 1, 2

Do not attribute hematuria to urinary tract infection without confirming infection resolution with repeat urinalysis 6 weeks post-treatment, as malignancy can coexist. 1, 3