What is the appropriate workup for a patient with asymptomatic visible hematuria (blood in urine) episodes lasting 3-5 days, with a history of 50 pack-years of smoking and uncontrolled hypertension (high blood pressure)?

Workup for Asymptomatic Gross Hematuria in High-Risk Patient

This patient requires urgent complete urologic evaluation with multiphasic CT urography and cystoscopy, regardless of whether the bleeding has currently resolved. 1, 2, 3

Why This Patient is High-Risk

Your patient has multiple high-risk features that mandate full evaluation:

• Gross (visible) hematuria: Carries a 30-40% malignancy risk—this alone requires urgent urologic referral even when self-limited 2, 3
• Age consideration: If male ≥60 years or female ≥60 years, this is high-risk by AUA criteria 1
• Smoking history: 50 pack-years places patient in high-risk category (>30 pack-years threshold) 1, 2
• Uncontrolled hypertension: Does not explain hematuria but may unmask underlying pathology 1

Required Workup Components

Immediate Laboratory Testing

• Urinalysis with microscopic examination: Confirm true hematuria (≥3 RBCs/HPF), assess for dysmorphic RBCs (>80% suggests glomerular source), red cell casts, proteinuria 1, 3
• Serum creatinine and complete metabolic panel: Evaluate renal function 1, 3
• Urine cytology: Recommended given high-risk status (age, smoking, gross hematuria history) to detect urothelial cancers 1, 3
• Urine culture: If infection suspected, obtain before antibiotics 2

Mandatory Imaging

Multiphasic CT urography is the preferred imaging modality for this high-risk patient 1, 2, 3:

• Detects renal cell carcinoma, transitional cell carcinoma, and urolithiasis
• Superior to ultrasound or traditional IVU for comprehensive upper tract evaluation 1

Mandatory Endoscopic Evaluation

Cystoscopy is non-negotiable for any patient with gross hematuria 1, 2, 3:

• Evaluates bladder mucosa for transitional cell carcinoma (most frequently diagnosed malignancy in hematuria cases)
• Assesses for bladder masses, urethral stricture, and benign prostatic hyperplasia
• Flexible cystoscopy preferred (less pain, equivalent diagnostic accuracy) 2

Critical Clinical Pitfalls to Avoid

Do not defer evaluation based on:

• Self-limited nature of bleeding: Gross hematuria requires full workup even if resolved 2, 3
• Uncontrolled hypertension: This may unmask pathology but does not explain hematuria 1
• Potential benign causes: Even if BPH or other benign condition identified, must exclude concurrent malignancy 2

Do not attribute hematuria to:

• Anticoagulation/antiplatelet therapy if patient is on these medications—they unmask underlying pathology requiring investigation 1, 2

When to Consider Nephrology Referral

Refer to nephrology if urinalysis shows 1, 3:

• Red cell casts (pathognomonic for glomerular disease)
• >80% dysmorphic RBCs (suggests glomerular source)
• Significant proteinuria (>500-1000 mg/24 hours or protein-to-creatinine ratio >0.2)
• Elevated or rising serum creatinine
• Tea-colored urine (suggests glomerular bleeding) 2

However, given the gross hematuria and smoking history, urologic evaluation takes priority and should not be delayed even if glomerular features are present 1, 3.

Follow-Up Protocol

If initial complete urologic workup is negative 1, 3:

• Repeat urinalysis at 6,12,24, and 36 months
• Monitor blood pressure at each visit
• Immediate re-evaluation warranted if:
  • Gross hematuria recurs
  • Significant increase in microscopic hematuria
  • New urologic symptoms develop
  • Development of hypertension, proteinuria, or glomerular bleeding features

The 30-40% malignancy risk with gross hematuria means this patient needs urgent urologic referral—do not wait for recurrence of visible bleeding. 2, 3 Bladder cancer can be preceded by hematuria for many years, making timely evaluation critical for mortality and morbidity outcomes 2.