What are the appropriate steps to take when experiencing hematuria (presence of large blood in urine)?

Urgent Urologic Referral Required for Gross Hematuria

All patients with visible blood in the urine (gross hematuria) require immediate urologic evaluation with cystoscopy and imaging, regardless of whether the bleeding stops on its own, because the risk of underlying malignancy exceeds 30-40%. 1, 2

Immediate Actions

• Refer urgently to urology within days, not weeks—gross hematuria carries a >10% cancer risk and up to 40% in some series, making this a potential oncologic emergency 1, 2, 3
• Do not wait for the bleeding to resolve before referring, as self-limited gross hematuria still mandates full evaluation 1, 2
• Order CT urography (multiphasic CT abdomen/pelvis with IV contrast) as the preferred imaging to detect renal cell carcinoma, transitional cell carcinoma, and urolithiasis 2, 3
• Check serum creatinine to assess renal function before contrast imaging 2, 3

Critical Diagnostic Steps

• Confirm true hematuria by obtaining microscopic urinalysis showing ≥3 red blood cells per high-powered field, though with gross hematuria this is typically obvious 1, 4
• Obtain urine culture if any symptoms suggest infection (dysuria, frequency, urgency), but do not delay urologic referral even if infection is present 2, 3
• Document associated symptoms: painless gross hematuria has stronger association with cancer than hematuria with flank pain (which suggests stones) 1, 5

What the Urologist Will Do

• Cystoscopy is mandatory to visualize the bladder mucosa, urethra, and ureteral orifices for transitional cell carcinoma, which is the most frequently diagnosed malignancy in hematuria cases 2, 3
• Flexible cystoscopy is preferred over rigid cystoscopy as it causes less pain with equivalent diagnostic accuracy 2, 3
• Upper tract imaging with CT urography will evaluate for renal masses and urothelial tumors 2, 3

Common Pitfalls to Avoid

• Never attribute gross hematuria to anticoagulation or antiplatelet therapy alone—these medications may unmask underlying pathology but do not cause hematuria themselves, and evaluation must proceed regardless 1, 2, 4
• Do not obtain urine cytology or molecular markers in the initial evaluation, as current guidelines do not recommend these tests for initial hematuria workup 1, 2
• Do not delay referral if the patient has benign prostatic hyperplasia (BPH)—BPH can cause hematuria but does not exclude concurrent malignancy 2
• Do not assume urinary tract infection explains the bleeding without confirming resolution of hematuria after treatment; persistent hematuria after treating UTI requires full urologic evaluation 2, 3

Risk Factors That Increase Malignancy Concern

• Age: males ≥60 years are highest risk; males 40-59 years are intermediate risk 2
• Smoking history: >30 pack-years confers high risk for urothelial carcinoma 2
• Occupational exposures: benzenes, aromatic amines, chemicals, or dyes 1, 2
• Irritative voiding symptoms (urgency, frequency, nocturia) without infection suggest possible bladder cancer 2
• History of prior gross hematuria significantly increases cancer risk 2

If Imaging and Cystoscopy Are Negative

• Repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring at each visit 2, 3
• Immediate re-evaluation is warranted if gross hematuria recurs, microscopic hematuria significantly increases, new urologic symptoms develop, or hypertension/proteinuria appears 2, 3
• Long-term surveillance is essential as hematuria can precede bladder cancer diagnosis by many years 3

When to Consider Nephrology Referral Instead

• Tea-colored or cola-colored urine suggests glomerular disease rather than urologic pathology 2
• Significant proteinuria (protein-to-creatinine ratio >0.2), red cell casts, or >80% dysmorphic RBCs indicate glomerular bleeding requiring nephrology evaluation 2, 3
• Elevated creatinine or declining renal function with hematuria warrants nephrology consultation 2

The bottom line: gross hematuria is cancer until proven otherwise in adults, and urologic evaluation cannot be deferred. 1, 3