Management of Urinary Urgency, Dysuria, and Hematuria
This patient requires immediate empiric antibiotic therapy for acute uncomplicated cystitis while simultaneously obtaining urine culture and initiating urgent urologic evaluation for the hematuria. 1, 2
Immediate Management
Confirm the Diagnosis
- Document the triad of symptoms: dysuria (burning), urgency, and hematuria are highly specific for acute cystitis when occurring together 1
- Dysuria has >90% accuracy for UTI diagnosis in young women when vaginal symptoms are absent 1, 3
- Obtain microscopic urinalysis to confirm ≥3 RBCs per high-power field and assess for pyuria (white blood cells) 1, 2
- Urine culture is mandatory before starting antibiotics given the presence of hematuria, which requires additional evaluation 1, 2
First-Line Antibiotic Treatment
Start empiric therapy immediately with one of the following first-line agents 1, 3:
- Nitrofurantoin 100 mg twice daily for 5-7 days (preferred due to low resistance rates) 1, 3, 4
- Fosfomycin trometamol 3 g single dose (convenient single-dose option) 1, 3
- Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days (only if local resistance <20%) 1, 3
Do NOT use fluoroquinolones as first-line therapy due to increasing resistance and adverse effects; reserve these for complicated infections 1, 3
Critical Hematuria Evaluation
The Hematuria Cannot Be Ignored
Hematuria in the setting of UTI symptoms still requires complete urologic evaluation once the infection is treated, particularly if any of the following apply 2, 5:
- Age >35-40 years (significantly increased malignancy risk) 2, 5
- Smoking history or occupational chemical exposure 2, 5
- Gross (visible) hematuria at any point 2, 5
- Persistent microscopic hematuria after UTI treatment 2, 5
Post-Treatment Follow-Up Protocol
After completing antibiotic therapy 1, 2:
Repeat urinalysis 2-4 weeks after treatment completion to document resolution of hematuria 1, 2
If hematuria persists (≥3 RBCs/HPF on microscopic exam), proceed with complete urologic evaluation 2, 5:
If hematuria resolves, continue monitoring with repeat urinalysis at 6,12,24, and 36 months 2, 5
Important Clinical Caveats
When to Pursue Immediate Urologic Evaluation
Do NOT wait for UTI treatment if any of these are present 2, 5:
- Gross (visible) hematuria - 30-40% malignancy risk mandates urgent urologic referral regardless of infection 2, 5
- Irritative voiding symptoms without documented infection on culture 2
- Recurrent UTIs with persistent hematuria between episodes 1, 2
- Age >60 years with any degree of hematuria 2, 5
Common Pitfalls to Avoid
- Never attribute hematuria solely to UTI without confirming resolution after treatment 2, 5
- Never delay evaluation for anticoagulation/antiplatelet therapy - these medications may unmask underlying pathology but do not cause hematuria 2, 5
- Never use fluoroquinolones empirically if the patient has used them in the last 6 months or is from a urology department (high resistance rates) 1
- Never treat asymptomatic bacteriuria if discovered incidentally after symptoms resolve 1
Distinguishing Glomerular from Urologic Hematuria
If hematuria persists after UTI treatment, determine the source 2, 5:
Suggests Glomerular (Nephrologic) Source:
- Tea-colored urine 2
80% dysmorphic RBCs on phase-contrast microscopy 2
- Red blood cell casts (pathognomonic for glomerular disease) 2
- Significant proteinuria (protein-to-creatinine ratio >0.2) 2
- Elevated serum creatinine 2
- → Requires nephrology referral 2, 5
Suggests Urologic Source:
- Bright red blood 2
- Normal-shaped RBCs 2
- Minimal or no proteinuria 2
- Normal renal function 2
- → Requires urology referral with cystoscopy and imaging 2, 5
Symptomatic Management
While awaiting culture results and antibiotic effect 1:
- Phenazopyridine (urinary analgesic) may provide symptomatic relief for dysuria 1
- Increased fluid intake to help flush bacteria 3
- Ibuprofen for pain relief (though antibiotics are superior to symptomatic management alone) 1