What is the best imaging approach for a 65-year-old male presenting with hematuria (blood in the urine)?

Imaging for Hematuria in a 65-Year-Old Male

Primary Recommendation

CT urography (CTU) without and with IV contrast is the imaging study of choice for evaluating hematuria in a 65-year-old male, demonstrating 96% sensitivity and 99% specificity for detecting urothelial malignancy. 1

Risk Stratification Context

A 65-year-old male automatically falls into the high-risk category for urologic malignancy based on age alone (>50 years), making comprehensive imaging mandatory regardless of whether hematuria is microscopic or gross. 2

• Additional risk factors to assess include smoking history, occupational chemical exposure, irritative voiding symptoms, or history of pelvic irradiation—any of which further solidifies the need for CTU. 2
• The American College of Radiology explicitly recommends CTU as usually appropriate for both microscopic hematuria with risk factors and gross hematuria in this population. 1

Technical Protocol Requirements

CTU must include three distinct phases to maximize diagnostic yield—this is non-negotiable:

• Unenhanced phase (kidneys to bladder): Essential for detecting renal calculi with 94-98% sensitivity, compared to only 52-59% for older intravenous urography. 1
• Nephrographic phase (post-contrast): Optimal for detecting renal masses and parenchymal abnormalities. 3
• Excretory phase (delayed imaging): Critical for visualizing urothelial lesions, filling defects, and upper tract transitional cell carcinoma with 99.6% accuracy for kidney/ureter lesions. 1, 2

Thin-slice acquisition (1-1.5mm) with multiplanar reformatting should be obtained to ensure comprehensive evaluation. 2, 4

Diagnostic Performance

CTU provides superior comprehensive evaluation compared to all alternative modalities:

• Upper tract lesions: 99.6% accuracy versus 84.9% for intravenous urography. 1
• Lower tract (bladder) lesions: 98.8% specificity and 97.2% accuracy. 1
• Direct comparison to MR urography: CTU provides better visibility of urothelial structures and improved diagnostic confidence. 1

The meta-analysis data supporting CTU shows pooled sensitivity of 96% and specificity of 99% for urothelial malignancy detection. 1

What NOT to Order

Common pitfalls to avoid:

• Do not order routine CT abdomen/pelvis with contrast instead of CTU—this lacks the pre-contrast and excretory phases necessary for comprehensive urinary tract evaluation and will miss critical pathology. 2
• Ultrasound is inadequate as first-line imaging in this high-risk patient, with only 35.3% sensitivity for bladder lesions and significantly lower detection rates for urinary tract abnormalities compared to CTU. 1, 2
• Intravenous urography (IVU) is obsolete—it has inferior sensitivity for renal masses and urothelial lesions compared to CTU and should not be used. 1, 2
• MRI abdomen/pelvis (non-urographic protocol) is not appropriate for hematuria evaluation as it lacks the specific phases needed for urinary tract assessment. 1

Special Circumstances

If CTU is contraindicated (e.g., impaired renal function with eGFR <45 mL/min or severe contrast allergy):

• MR urography without and with IV contrast becomes the most appropriate alternative imaging modality. 2
• MRU has comparable accuracy to CT for renal mass characterization but decreased spatial resolution for small calculi and urothelial lesions. 1

Clinical Context

In a retrospective analysis of 771 patients with hematuria undergoing CTU, clinically significant findings were identified in 42% of cases, with tumors/complex cysts found in 18% and calculi in 9%. 5 The detection rate is higher in gross versus microscopic hematuria (48% vs. 29%), but the comprehensive evaluation remains essential regardless. 5

CTU serves as both a diagnostic and triage test, potentially eliminating the need for multiple sequential imaging studies and enabling earlier diagnosis of bladder cancer, upper tract urothelial carcinoma, renal cell carcinoma, and urolithiasis. 6