What is the appropriate management for a patient presenting with frank hematuria?

Management of Frank (Gross) Hematuria

Frank hematuria requires immediate and complete urologic evaluation with cystoscopy and upper tract imaging (preferably multiphasic CT urography), regardless of whether the bleeding is self-limited or a benign cause is suspected, because gross hematuria carries a 30-40% risk of malignancy. 1, 2

Immediate Diagnostic Workup

Laboratory Evaluation

• Confirm true hematuria with microscopic urinalysis showing ≥3 RBCs per high-power field, though with frank hematuria this is typically obvious 1, 3
• Complete urinalysis with microscopy to assess for dysmorphic RBCs (>80% suggests glomerular source), red cell casts (pathognomonic for glomerular disease), and proteinuria 1, 3
• Urine culture if infection suspected, preferably before starting antibiotics 1, 3
• Serum creatinine, BUN, and complete metabolic panel to evaluate renal function 1, 3
• Voided urine cytology in high-risk patients (age >60, smoking history >30 pack-years, occupational chemical exposure) 1, 4

Imaging Studies

• Multiphasic CT urography is the preferred imaging modality for detecting renal cell carcinoma, transitional cell carcinoma, and urolithiasis in all patients with gross hematuria 1, 3, 5
• Traditional intravenous urography remains acceptable but has limited sensitivity for small renal masses 1
• Renal ultrasound alone is insufficient for comprehensive upper tract evaluation in adults with gross hematuria 1

Endoscopic Evaluation

• Cystoscopy is mandatory for all patients with gross hematuria to evaluate the bladder for transitional cell carcinoma, which is the most frequently diagnosed malignancy in hematuria cases 1, 3
• Flexible cystoscopy is preferred over rigid cystoscopy as it causes less pain with equivalent or superior diagnostic accuracy 1

Critical Clinical Considerations

Do Not Defer Evaluation For:

• Anticoagulation or antiplatelet therapy - these medications may unmask underlying pathology but do not cause hematuria themselves; evaluation must proceed regardless 1, 3
• Identified benign causes (e.g., UTI, BPH) - concurrent malignancy must still be excluded in patients with gross hematuria 1, 4
• Self-limited episodes - even single episodes of gross hematuria require full evaluation due to high malignancy risk 1, 2

Age-Specific Risk Stratification

• Males ≥60 years are classified as high-risk and require cystoscopy and CT urography regardless of other factors 1
• Males 40-59 years are intermediate-risk and require shared decision-making about cystoscopy and imaging 1
• History of gross hematuria significantly increases cancer risk (odds ratio 7.2) even in younger patients 3

Urine Color as Diagnostic Clue

• Bright red blood suggests lower urinary tract bleeding (bladder, prostate, urethra) 1
• Tea-colored or cola-colored urine indicates glomerular disease and warrants nephrology referral in addition to urologic evaluation 1, 3

When to Involve Nephrology

Nephrology referral is indicated if any of the following are present: 1, 3

• Dysmorphic RBCs >80% with red cell casts
• Significant proteinuria (protein-to-creatinine ratio >0.2 or >500 mg/24 hours)
• Elevated serum creatinine or declining renal function
• Hypertension with hematuria and proteinuria

Important caveat: Even with suspected glomerular disease, complete urologic evaluation must still be performed if hematuria persists, as glomerular and urologic pathology can coexist 1, 3

Follow-Up Protocol After Negative Initial Evaluation

If initial comprehensive workup is negative but gross hematuria recurs: 1, 3, 6

• Repeat complete urologic evaluation including imaging and cystoscopy
• Approximately 10% of patients with recurrent gross hematuria after initially negative workup will be diagnosed with urological malignancy on repeat evaluation 6
• Annual urinalysis at 6,12,24, and 36 months with blood pressure monitoring at each visit 1, 3
• Comprehensive re-evaluation in 3-5 years if hematuria persists or recurs 3

Immediate Re-Evaluation Triggers

Warrant urgent repeat evaluation: 1, 3

• Development of new urologic symptoms (flank pain, dysuria, irritative voiding symptoms)
• Significant increase in degree of hematuria
• Development of hypertension or proteinuria
• New constitutional symptoms suggesting malignancy

Common Pitfalls to Avoid

• Never attribute gross hematuria solely to medications (anticoagulants, antiplatelets) without complete evaluation 1, 3
• Do not stop evaluation after treating UTI - repeat urinalysis 6 weeks after antibiotic completion to confirm resolution; persistent hematuria requires full urologic workup 3
• Do not assume BPH explains gross hematuria in older men without proving prostatic origin through appropriate evaluation 1
• Hematuria can precede bladder cancer diagnosis by many years, making long-term surveillance essential in high-risk patients 1