What is the management for a patient with CVA (costovertebral angle) tenderness and hematuria?

Management of CVA Tenderness with Isolated Hematuria

This 58-year-old female with CVA tenderness and isolated hematuria (+2 blood on dipstick, negative nitrites/leukocytes) requires urgent urologic evaluation with CT urography and cystoscopy, as this presentation carries a significant risk of urinary tract malignancy that cannot be excluded by the absence of infection markers. 1, 2

Immediate Diagnostic Steps

Confirm True Hematuria

• Do not proceed with extensive workup based solely on dipstick results - dipstick tests have only 65-99% specificity and can produce false positives 1
• Obtain microscopic urinalysis immediately to confirm ≥3 red blood cells per high-power field on a properly collected clean-catch midstream specimen 1, 2
• If microscopic examination confirms hematuria, proceed with full evaluation regardless of symptom resolution 2

Risk Stratification for This Patient

This patient falls into intermediate-to-high risk category based on: 1

• Age 58 years (women ≥60 years are intermediate risk, but close proximity warrants heightened concern)
• Presence of flank pain/CVA tenderness (suggests upper tract pathology)
• Hematuria confirmed on urinalysis

Complete Urologic Evaluation Required

Upper Tract Imaging

CT urography (multiphasic CT with IV contrast) is the mandatory first-line imaging modality for this presentation, as it provides comprehensive evaluation for: 1, 2

• Renal cell carcinoma
• Transitional cell carcinoma of the upper urinary tract
• Urolithiasis (though less likely given negative leukocytes/nitrites)
• Other structural abnormalities

Alternative imaging only if CT contraindicated: 2

• MR urography if contrast allergy or severe renal dysfunction
• Renal ultrasound with retrograde pyelography as last resort (insufficient as sole modality) 1

Lower Tract Evaluation

• Cystoscopy is mandatory to exclude bladder transitional cell carcinoma, which is the most frequently diagnosed malignancy in hematuria cases 1, 2
• Flexible cystoscopy preferred (less painful, equivalent diagnostic accuracy) 1

Laboratory Workup

• Serum creatinine and complete metabolic panel to assess renal function and exclude glomerular disease 1, 2
• Urine culture even with negative dipstick, as lower bacterial counts may be clinically significant but not detected on dipstick 3, 1
• Urine cytology given intermediate-high risk status for detecting high-grade urothelial cancers 1, 2

Distinguishing Urologic vs. Glomerular Source

Features Suggesting Urologic (Non-Glomerular) Source - Most Likely Here:

• Normal-shaped RBCs on microscopy (not dysmorphic) 1, 2
• Minimal or absent proteinuria 1, 2
• Normal serum creatinine 1, 2
• Unilateral flank pain/CVA tenderness 2

Features That Would Suggest Glomerular Source:

• 80% dysmorphic RBCs or red cell casts 1

• Significant proteinuria (protein-to-creatinine ratio >0.2) 1
• Elevated serum creatinine 1, 2
• Tea-colored urine 1

If glomerular features present, add nephrology referral alongside urologic evaluation 1, 2

Critical Management Principles

Do Not Delay Evaluation For:

• Anticoagulation or antiplatelet therapy - these medications unmask underlying pathology rather than causing hematuria; full evaluation still required 1, 2, 4
• Self-resolution of symptoms - even transient gross hematuria requires complete workup 2, 5
• Presumed benign causes - CVA tenderness with hematuria may suggest nephrolithiasis, but malignancy must be excluded first 6

Common Pitfalls to Avoid:

• Anchoring on nephrolithiasis diagnosis without imaging confirmation - flank pain and hematuria can represent renal masses, upper tract urothelial carcinoma, or other serious pathology 6
• Assuming negative nitrites/leukocytes excludes all pathology - this only reduces likelihood of bacterial cystitis, not malignancy or other causes 1, 2
• Relying on dipstick alone - must confirm with microscopy showing ≥3 RBCs/HPF 1

Urgent Urologic Referral Indications

This patient meets criteria for urgent urology referral based on: 1, 2

• Confirmed hematuria (once microscopy performed)
• Age >35 years
• Symptomatic presentation (CVA tenderness)
• Intermediate-high risk profile

The urologist will coordinate: 1, 2

• CT urography timing and protocol
• Cystoscopy scheduling
• Interpretation of all findings
• Further management based on results

Follow-Up Protocol If Initial Workup Negative

If comprehensive evaluation reveals no malignancy or significant pathology: 1, 2

• Repeat urinalysis at 6,12,24, and 36 months
• Monitor blood pressure at each visit
• Immediate re-evaluation if: recurrent gross hematuria, significant increase in microscopic hematuria, new urologic symptoms, or development of hypertension/proteinuria
• Consider nephrology referral if hematuria persists with proteinuria or evidence of glomerular bleeding 1, 2

The 30-40% malignancy risk with gross hematuria and 2.6-4% risk with microscopic hematuria in this age group mandates aggressive evaluation - conservative observation is inappropriate until malignancy is excluded. 1, 2, 5