What is the evaluation and treatment approach for painless hematuria?

Evaluation and Treatment of Painless Hematuria

Initial Approach Based on Patient Age and Presentation

The evaluation of painless hematuria fundamentally differs between adults and children, with adults requiring urologic referral for cystoscopy and imaging to exclude malignancy, while children with isolated microscopic hematuria and no proteinuria typically need no imaging at all. 1, 2

Adults with Painless Hematuria

All adults with gross hematuria, even if self-limited, require urologic referral for comprehensive evaluation including cystoscopy and imaging. 1 The risk of underlying cancer is consistently >10% and can exceed 25% in referral series. 1

For adults with microscopic hematuria:

• Confirm hematuria with microscopic examination before initiating further evaluation in all asymptomatic adults 1
• Refer for urologic evaluation with cystoscopy and imaging in adults with microscopically confirmed hematuria in the absence of demonstrable benign cause 1
• Pursue evaluation even if the patient is receiving antiplatelet or anticoagulant therapy, as hematuria in anticoagulated patients still indicates underlying pathology requiring investigation 1, 3
• Do not obtain urinary cytology or other urine-based molecular markers for bladder cancer detection in the initial evaluation 1

The probability of occult cancer in asymptomatic microscopic hematuria ranges from 0.5% to 5.0%, with higher-risk subgroups (older age, male sex, smoking history) showing rates of 7% to >20%. 1

Children with Painless Hematuria

The approach in children is dramatically different and depends on whether hematuria is microscopic or macroscopic, and whether proteinuria is present.

Isolated Microscopic Hematuria WITHOUT Proteinuria

No imaging or further workup is required for children with isolated microscopic hematuria who lack proteinuria or dysmorphic red blood cells. 1, 2 A study of 325 pediatric patients with microscopic hematuria found no clinically significant findings on renal ultrasound (87% underwent US) or voiding cystourethrography (24% underwent VCUG). 1, 2

Key evaluation steps:

• Perform thorough urinalysis with microscopic examination to differentiate glomerular from non-glomerular causes 2
• Check for proteinuria, dysmorphic red blood cells, and red cell casts, which indicate glomerular disease requiring nephrology referral 2, 4
• Screen family members' urine for benign familial hematuria (thin basement membrane nephropathy, Alport syndrome) 1
• Evaluate for hypercalciuria using spot urine calcium-to-creatinine ratio 2

Critical pitfall to avoid: Advanced imaging (CT, MRI, VCUG) is not appropriate for isolated, transient microscopic hematuria in an otherwise well child and exposes the child to unnecessary risk. 2, 4 Isolated microscopic hematuria is very rarely the presenting scenario of Wilms tumor. 1, 2

Isolated Macroscopic (Gross) Hematuria

Renal and bladder ultrasound is the initial imaging modality of choice for isolated macroscopic hematuria in children. 1, 2 Isolated asymptomatic macroscopic hematuria is usually due to benign processes such as hypercalciuria and IgA nephropathy, but imaging is needed to exclude nephrolithiasis, urologic abnormalities, and rarely renal or bladder tumors. 1

Ultrasound technique:

• Examine both kidneys and bladder with the bladder distended with urine to optimize assessment 1
• Assess for bladder lesions including polyps, masses, or vascular lesions 1
• Plain radiography may be performed concurrently to detect calcifications and radiopaque stones 2

If unexplained hematuria persists despite negative ultrasound and there is concern for bladder urothelial neoplasm, cystoscopy may be indicated. 1

If a renal or bladder mass is detected by ultrasound, further imaging with CT or MRI is required to define local extent of disease, vascular invasion (in Wilms tumor), and detect metastases. 1

Microscopic Hematuria WITH Proteinuria

The presence of proteinuria changes the clinical picture entirely:

• Indicators of glomerular hematuria include tea-colored urine with proteinuria, red blood cell casts, and dysmorphic red blood cells on phase contrast microscopy 2
• These findings suggest glomerulonephritis and warrant nephrology referral rather than imaging 2
• When chronic kidney disease is suspected, obtain blood urea nitrogen, serum creatinine, and complete blood count with platelets 2

Special Clinical Scenarios

Painful Hematuria (Suspected Urolithiasis)

For painful hematuria suspected to be due to urolithiasis, ultrasound of the kidneys and bladder is first-line imaging, though it has limited sensitivity for ureteral stones. 2

CT may be particularly useful in painful hematuria with negative kidney and bladder ultrasound and high clinical suspicion for urolithiasis, especially if detection would impact treatment. 2 CT has sensitivity and specificity both well above 90% for stone detection in adults, with proper low-dose techniques reducing radiation to less than traditional IVU. 2

Hematuria with Palpable Abdominal Mass

Urgent ultrasound evaluation is required when hematuria is accompanied by a palpable abdominal mass, as this raises concern for Wilms tumor or other renal masses. 2, 5

Critical evaluation steps:

• Ultrasound must confirm renal origin of the mass, assess the contralateral kidney, evaluate for inferior vena cava involvement, and determine tumor size and extent 2, 5
• After ultrasound confirms a renal mass, proceed urgently to chest CT for staging and consider contrast-enhanced abdominal CT or MRI to define local extent and vascular invasion 2, 5

Critical pitfall: Delaying imaging by assuming isolated hematuria requires no workup is dangerous when an abdominal mass is present. 2 The abdominal mass must be characterized first to guide subsequent management. 5

Traumatic Hematuria

Macroscopic hematuria following trauma necessitates radiologic evaluation with contrast-enhanced CT of the abdomen and pelvis. 2

All CT scans must be performed with intravenous contrast unless specifically contraindicated. 2

Indications for imaging in traumatic hematuria:

• ≥50 red blood cells on urinalysis 2
• Hypotension on presentation (though this is an unreliable clinical indicator in children) 2
• Mechanism of injury 2
• Blood in the urethral meatus with pelvic fractures (50% incidence of genitourinary injury) 2

Isolated microscopic hematuria without clinical or laboratory findings of visceral trauma or concerning mechanism does not need emergency investigation. 2

Key Historical and Physical Examination Elements

For children presenting with hematuria, elicit:

• Recent streptococcal infection, family history of renal disease or hearing loss, sickle cell disease, bleeding disorders, urolithiasis, recent trauma, strenuous exercise, menstruation, dysuria, flank pain, and medications 2
• Urinary tract infection symptoms, tropical exposure, bloody diarrhea, joint pains, rash, frequency, occult trauma, foreign body insertion 2

Physical examination priorities:

• Assess for fevers, arthritis, rashes, soft-tissue edema, nephromegaly, abdominal masses, genital or anal bleeding suggesting abuse, deafness, and costovertebral angle tenderness 2
• Measure height and weight as indicators of chronic disease 2

Treatment Approach

There is no specific treatment to resolve or prevent hematuria itself. 6 Resolution of hematuria usually occurs with appropriate management of the underlying disorder. 6

The treatment strategy depends entirely on the identified cause:

• Urologic malignancies require surgical intervention and oncologic management 3
• Urolithiasis may require medical expulsive therapy or urologic intervention
• Glomerulonephritis requires nephrology management with immunosuppression when indicated
• Urinary tract infections require appropriate antimicrobial therapy
• Benign causes (hypercalciuria, thin basement membrane nephropathy) typically require only monitoring

Persistent microscopic hematuria indicates the presence of renal disease that warrants close monitoring and evaluation. 6