What is the appropriate evaluation and management for a male patient presenting to the emergency room with hematuria?

History of Present Illness for Male Patient with Hematuria

Chief Complaint and Onset

• Document whether the blood is visible to the naked eye (gross hematuria) or was detected only on urinalysis (microscopic hematuria), as gross hematuria carries a 30-40% risk of malignancy and requires urgent urologic evaluation regardless of whether it is self-limited 1, 2.
• Establish the exact timing of onset, duration, and whether this is the first episode or recurrent 3.
• Specifically ask about any history of self-limited visible blood in the urine over the past 6 months, as 19.8% of patients with microscopic hematuria report prior gross hematuria when directly questioned, and this significantly increases cancer risk 1, 2.

Characterization of Hematuria

• Determine the color of the urine: bright red suggests lower urinary tract bleeding, while tea-colored or cola-colored urine indicates glomerular disease 1, 2.
• Ask whether blood appears at the beginning of urination (urethral source), throughout the stream (bladder or upper tract), or at the end (bladder neck or prostatic) 4.
• Quantify the amount and frequency of visible blood if gross hematuria is present 3.

Associated Symptoms

• Document the presence or absence of pain, as painless gross hematuria in elderly males is caused by malignancy until proven otherwise 4, 2.
• Ask specifically about flank pain (suggests nephrolithiasis, renal mass, or rarely Page kidney), suprapubic pain (bladder pathology), or dysuria (infection or bladder lesion) 1, 5.
• Inquire about irritative voiding symptoms including urgency, frequency, and nocturia, as these are high-risk features for urothelial malignancy even without infection 1, 2.
• Ask about fever, chills, or other systemic symptoms suggesting infection 1.
• Document any recent trauma, even minor, as subcapsular hematoma can present with flank pain and hematuria mimicking nephrolithiasis 5.

Critical Risk Factors for Malignancy

• Obtain detailed smoking history in pack-years: <10 pack-years is low risk, 10-30 pack-years is intermediate risk, and >30 pack-years is high risk for urothelial carcinoma 1, 6.
• Document occupational exposure to chemicals or dyes, specifically benzenes and aromatic amines used in rubber, leather, textile, and paint industries 1, 2.
• Ask about history of pelvic irradiation or cyclophosphamide exposure 6, 7.
• Inquire about chronic analgesic abuse, particularly phenacetin-containing compounds 6, 7.

Medical History

• Document any history of urologic disorders including prior bladder tumors, kidney stones, or benign prostatic hyperplasia, though BPH does not exclude concurrent malignancy 2, 6.
• Ask about recurrent urinary tract infections, as this increases risk and may mask underlying pathology 1, 7.
• Inquire about kidney disease, hypertension, or family history of kidney disease (suggests glomerular cause) 1, 2.
• Document any history of sickle cell disease or bleeding disorders 1.

Medication History

• List all anticoagulants and antiplatelet agents (warfarin, DOACs, aspirin, clopidogrel), but emphasize that these medications do not cause hematuria—they only unmask underlying pathology that requires full investigation 1, 2.
• Document any recent use of medications that can discolor urine (rifampin, phenazopyridine) to distinguish from true hematuria 3.
• Ask about recent use of cyclophosphamide or other chemotherapeutic agents 6.

Recent Events and Exposures

• Ask about vigorous exercise within 24-48 hours, as this can cause transient hematuria that should resolve on repeat testing 1, 2.
• Inquire about recent sexual activity or instrumentation of the urinary tract 7.
• For premenopausal women, document timing relative to menstrual cycle to exclude contamination 1, 2.
• Ask about recent viral illness, as this can cause transient hematuria 1, 7.

Review of Systems

• Specifically ask about any prior episodes of visible blood in urine, even if brief and self-limited, as patients commonly fail to report this critical symptom unless directly questioned 1, 2.
• Document presence of edema, foamy urine (proteinuria), or decreased urine output suggesting glomerular disease 1, 2.
• Ask about constitutional symptoms including weight loss, night sweats, or fatigue that may suggest malignancy 3.
• Inquire about joint pain, rash, or hearing loss (suggests systemic disease like lupus or Alport syndrome) 1, 2.

Age-Specific Considerations

• For males ≥60 years old, classify as high-risk requiring cystoscopy and CT urography regardless of other factors 1, 6.
• For males 40-59 years old, classify as intermediate-risk requiring shared decision-making about cystoscopy and imaging 1, 6.
• For males <40 years old, risk stratification depends on smoking history, degree of hematuria, and other risk factors 1, 6.