From the Guidelines
Inpatient workup for hematuria should begin with a thorough history and physical examination, followed by urinalysis with microscopy to confirm the presence of red blood cells, as recommended by the American College of Radiology 1 and the American Urological Association 1. Initial laboratory tests should include complete blood count, comprehensive metabolic panel, and coagulation studies. Imaging studies are essential, typically starting with renal ultrasound or CT urography to evaluate the kidneys, ureters, and bladder, with CT urography being the imaging procedure of choice due to its high sensitivity and specificity for imaging the upper tracts 1. Cystoscopy is often necessary to directly visualize the bladder and urethra, particularly in patients over 35 years old or those with risk factors for malignancy, with a sensitivity ranging from 87% to 100% and specificity ranging from 64% to 100% 1. If the patient has gross hematuria with clots or severe pain, a three-way Foley catheter may be placed for bladder irrigation using normal saline at 150-200 mL/hour to prevent clot formation. Additional specialized tests may include urine cytology to detect malignant cells, and in some cases, renal biopsy if glomerular disease is suspected. The workup should be tailored based on risk factors such as age, smoking history, chemical exposures, medication use (particularly anticoagulants), and family history, with urgent consultation with urology warranted for patients with gross hematuria, clot retention, or hemodynamic instability 1. This systematic approach helps identify the underlying cause, which may range from urinary tract infection and nephrolithiasis to more serious conditions like malignancy or glomerulonephritis. Key considerations include:
- Confirming heme-positive results of dipstick testing with microscopic urinalysis that demonstrates 3 or more erythrocytes per high-powered field before initiating further evaluation in all asymptomatic adults 1
- Referring for further urologic evaluation in all adults with gross hematuria, even if self-limited 1
- Considering urology referral for cystoscopy and imaging in adults with microscopically confirmed hematuria in the absence of some demonstrable benign cause 1
- Pursuing evaluation of hematuria even if the patient is receiving antiplatelet or anticoagulant therapy 1
From the Research
Inpatient Workup for Hematuria
The inpatient workup for hematuria involves a comprehensive evaluation to determine the underlying cause of the condition.
- The initial step includes a focused history and physical examination to identify potential causes of hematuria 2.
- Laboratory studies, such as urine culture, and diagnostic imaging, including intravenous pyelography and cystoscopy, are essential in revealing the source of hematuria in many cases 3.
- A systematic approach to evaluating hematuria is crucial, as it can have a broad differential diagnosis ranging from insignificant etiology to potentially life-threatening neoplastic lesions 4.
Diagnostic Tests
The following diagnostic tests are commonly used in the inpatient workup for hematuria:
- Urine culture to identify urinary tract infections 3, 5
- Intravenous pyelography to evaluate the upper urinary tract 3, 4
- Cystoscopy to evaluate the lower urinary tract 3, 5, 4
- Microscopic urinalysis to distinguish glomerular from nonglomerular sources of bleeding 4
- Renal ultrasonography or computed tomography to determine the location and characteristics of lesions 4
Importance of Early Evaluation
Early and appropriate evaluation of hematuria is essential, as it can signal the presence of urologic malignancy, especially in the elderly 2.
- Prompt evaluation and referral of patients with documented hematuria should be initiated in the primary care setting according to proposed guidelines, aiming at cost-effective and early detection of urologic abnormality 5.