What is the appropriate evaluation and management for a 28-year-old woman presenting with gross hematuria?

Gross Hematuria in a 28-Year-Old Woman

This patient requires urgent urologic evaluation with cystoscopy and upper tract imaging (CT urography), regardless of any presumed benign cause, because gross hematuria carries a 30-40% risk of underlying malignancy. 1, 2

Immediate Management

Seek same-day or next-day medical attention for any episode of gross hematuria, even if self-limited. 1 The critical distinction here is that gross (visible) hematuria demands a fundamentally different approach than microscopic hematuria—it cannot be observed or attributed to benign causes without complete evaluation. 1, 2

Initial Assessment Steps

• Confirm true hematuria with urinalysis and microscopic examination showing ≥3 RBCs per high-power field to exclude pseudohematuria from menstruation, foods, or medications. 1, 2

• Obtain detailed history focusing on:

  • Smoking history with pack-year quantification (even minimal smoking increases risk) 3
  • Occupational exposures to chemicals, dyes, benzenes, or aromatic amines 3, 2
  • Irritative voiding symptoms (urgency, frequency, dysuria) which may indicate bladder pathology 3
  • Family history of urologic malignancies or genetic risk factors 3
  • Recent vigorous exercise, trauma, or menstrual timing 2

• Perform physical examination including blood pressure measurement and assessment for flank masses or tenderness. 3

• Order baseline laboratory tests:

  • Serum creatinine to assess renal function 3, 1
  • Urine culture if infection suspected based on symptoms 1, 2
  • Complete urinalysis with microscopic examination 1

Risk Stratification for This Patient

Using the 2025 AUA/SUFU Risk Stratification System, this 28-year-old woman would typically fall into the low-risk category based on age alone (<60 years). 3 However, the presence of gross hematuria automatically elevates her to requiring full evaluation regardless of other risk factors. 3, 1

The updated 2025 guidelines specifically recognize that women have significantly lower risk of urothelial malignancy than previously thought, with women <60 years now classified as low-risk and women ≥60 years as intermediate-risk (women cannot be categorized as high-risk based on age alone). 3 Despite this lower baseline risk, gross hematuria mandates complete workup. 1, 2

Required Urologic Evaluation

Upper Tract Imaging

Multiphasic CT urography is the preferred imaging modality to detect renal cell carcinoma, transitional cell carcinoma, and urolithiasis. 2, 4 This provides comprehensive evaluation of the kidneys, ureters, and collecting system in a single study. 2

• Traditional intravenous urography remains acceptable but has limited sensitivity for small renal masses. 2
• Renal ultrasound alone is insufficient for comprehensive upper tract evaluation. 2

Lower Tract Evaluation

Cystoscopy is mandatory for all patients with gross hematuria to evaluate the bladder for transitional cell carcinoma, which is the most frequently diagnosed malignancy in hematuria cases. 2, 4 Flexible cystoscopy causes less pain and has equivalent or superior diagnostic accuracy compared to rigid cystoscopy. 2

Additional Testing Considerations

• Urine cytology may be considered if there are risk factors for carcinoma in situ or irritative voiding symptoms, though it is not routinely recommended for all patients. 4
• Do not obtain urine-based molecular markers in the initial evaluation, as they are not recommended by current guidelines. 2

Critical Pitfalls to Avoid

• Never attribute gross hematuria solely to exercise, menstruation, or other benign causes without complete urologic evaluation—even in young, healthy individuals. 1, 2 History of even self-limited gross hematuria increases cancer risk 7.2-fold. 1

• Do not delay evaluation even if the hematuria resolves spontaneously. 1 The 30-40% malignancy association with gross hematuria far exceeds the 2.6-4% risk with microscopic hematuria. 1, 2

• Anticoagulation or antiplatelet medications (if present) do not explain hematuria and should not defer evaluation—these medications may simply unmask underlying pathology requiring investigation. 2, 4

• Do not assume urinary tract infection is the sole cause without completing full evaluation after infection treatment, as infection can coexist with malignancy. 2

Distinguishing Glomerular vs. Non-Glomerular Sources

While awaiting urologic evaluation, assess for signs suggesting glomerular (kidney) disease that would warrant nephrology involvement:

• Tea-colored urine (rather than bright red) suggests glomerular source. 2
• Dysmorphic RBCs (>80%) or red cell casts on microscopy indicate glomerular bleeding. 2
• Significant proteinuria (protein-to-creatinine ratio >0.2 g/g) suggests renal parenchymal disease. 2
• Elevated creatinine or declining renal function warrants nephrology referral. 2

For this young woman with gross hematuria, the urinary sediment showing normal-appearing RBCs without casts suggests a urologic (non-glomerular) source, making the urologic evaluation the priority. 4

Follow-Up After Negative Initial Evaluation

If the complete urologic workup (cystoscopy and CT urography) is negative:

• Repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring at each visit. 1, 2
• Immediate re-evaluation is warranted if:
  • Recurrent gross hematuria develops 1
  • Significant increase in degree of microscopic hematuria occurs 2
  • New irritative voiding symptoms appear without infection 1
  • Development of hypertension, proteinuria, or evidence of glomerular bleeding 2

Special Considerations for Young Women

The 2025 AUA/SUFU guidelines represent a significant update recognizing that women have substantially lower risk of urothelial malignancy than men, with interval studies showing significantly lower risk particularly in younger women. 3 However, this does not diminish the need for complete evaluation of gross hematuria, as the 30-40% malignancy risk applies across demographics. 1, 2

Menstrual contamination must be excluded by ensuring proper specimen collection (clean-catch midstream urine collected when not menstruating) before attributing hematuria to menstruation. 2 True gross hematuria visible throughout urination requires full workup regardless of menstrual timing. 1