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

History of Present Illness Template for Male Patient with Hematuria

Chief Complaint

[Patient Name] is a [age]-year-old male who presents to the emergency department with [gross/microscopic] hematuria.

Onset and Characteristics of Hematuria

• Timing: First noticed [date/time], [single episode vs. intermittent vs. continuous] 1
• Color description: [bright red/pink-tinged/tea-colored/cola-colored] (tea-colored suggests glomerular source; bright red suggests lower urinary tract) 2
• Clots present: [yes/no] (clots suggest non-glomerular source) 3
• Timing during urination: [initial/throughout/terminal] (initial suggests urethral source; terminal suggests bladder neck/prostate) 3

Associated Symptoms

• Pain: [flank pain/suprapubic pain/dysuria/painless] (painless gross hematuria in elderly suggests malignancy) 2, 3
• Irritative voiding symptoms: [urgency/frequency/nocturia] (high-risk features for urothelial malignancy) 2
• Constitutional symptoms: [fever/chills/weight loss/night sweats] 1
• Recent trauma: [yes/no, describe mechanism] 2

Risk Factors for Malignancy (Critical in Males ≥40 Years)

• Age: [specific age] (males ≥60 years are high-risk; 40-59 years intermediate-risk) 1, 2
• Smoking history: [never smoker/<10 pack-years/10-30 pack-years/>30 pack-years] (>30 pack-years is high-risk) 1, 2
• Occupational exposure: [chemicals/dyes/benzenes/aromatic amines] 1, 2
• History of gross hematuria: [prior episodes, when] (significantly increases cancer risk) 1, 2
• History of urologic disorders: [bladder cancer/kidney stones/BPH/recurrent UTIs] 1, 2

Potential Benign Causes to Exclude

• Recent vigorous exercise: [yes/no, type and timing] 1, 2
• Recent UTI symptoms: [dysuria/frequency/urgency] 1
• Sexual activity or trauma: [recent, timing] 1
• Menstrual contamination: N/A for male patient 2

Medications

• Anticoagulants/antiplatelets: [warfarin/aspirin/clopidogrel/DOACs] (do not explain hematuria but may unmask pathology—full evaluation still required) 1, 2
• Phenazopyridine (Azo): [yes/no, last dose] (interferes with urinalysis; discontinue 48-72 hours before testing) 4
• Analgesics: [NSAIDs/chronic analgesic use] (analgesic nephropathy risk) 1
• Tadalafil (Cialis): [yes/no] (does not cause hematuria; investigate underlying pathology) 2

Medical History

• Kidney disease: [chronic kidney disease/glomerulonephritis/polycystic kidney disease] 2
• Hypertension: [yes/no, controlled/uncontrolled] (with hematuria suggests glomerular disease) 1, 2
• Diabetes: [yes/no] 2
• Sickle cell disease: [yes/no] (causes renal papillary necrosis) 2
• Coagulopathy: [hemophilia/von Willebrand disease] 2
• History of pelvic irradiation: [yes/no, indication] 1

Family History

• Kidney disease: [polycystic kidney disease/Alport syndrome/thin basement membrane disease] 1, 2
• Hearing loss: (suggests Alport syndrome if present with hematuria) 2
• Urologic malignancies: [bladder/kidney cancer in family members] 2

Review of Systems for Glomerular Disease

• Proteinuria indicators: [foamy urine/edema] 1
• Systemic symptoms: [rash/joint pain/recent infection] (suggests post-infectious GN or vasculitis) 1, 2
• Hearing loss: (Alport syndrome) 2

Physical Examination Findings

• Vital signs: Blood pressure [value] (hypertension with hematuria suggests glomerular disease) 1
• Abdominal examination: [costovertebral angle tenderness/suprapubic tenderness/palpable masses] 2, 3
• Genitourinary examination: [blood at urethral meatus/scrotal masses/testicular abnormalities] 2
• Skin: [rash/petechiae/purpura] (suggests vasculitis or coagulopathy) 2
• Edema: [periorbital/peripheral] (suggests glomerular disease with proteinuria) 1

Initial Diagnostic Testing in ED

• Urinalysis with microscopy: [≥3 RBCs/HPF confirms true hematuria; evaluate for dysmorphic RBCs >80%, red cell casts, proteinuria] 1, 4
• Urine culture: [if infection suspected, obtain before antibiotics] 1, 2
• Serum creatinine/BUN: [evaluate renal function] 1, 2
• Complete blood count: [evaluate for anemia, thrombocytopenia] 2

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Clinical Decision Point: Gross hematuria in males carries a 30-40% malignancy risk and requires urgent urologic referral regardless of whether self-limited 1, 2, 3. Anticoagulation does not explain hematuria and should not defer evaluation 1, 2.