What are the treatment options for hematuria?

Diseases and Treatment Approach for Hematuria

The treatment of hematuria depends entirely on identifying and addressing the underlying cause, which ranges from benign conditions requiring only observation to life-threatening malignancies demanding urgent intervention. 1, 2

Initial Confirmation and Exclusion of Benign Causes

Before pursuing extensive workup, confirm true hematuria with microscopic urinalysis showing ≥3 RBCs per high-power field on at least two of three properly collected clean-catch midstream specimens—dipstick alone has only 65-99% specificity and produces false positives from myoglobinuria, hemoglobinuria, or menstrual contamination. 1, 2

Exclude transient benign causes first: 1

• Menstruation in women
• Vigorous exercise within 48-72 hours
• Recent sexual activity
• Viral illness
• Trauma
• Urinary tract infection

If UTI is suspected, obtain urine culture before starting antibiotics, treat appropriately, then repeat urinalysis 6 weeks after treatment completion to confirm hematuria resolution. 1

Risk Stratification Determines Treatment Intensity

The American Urological Association stratifies patients into three risk categories that fundamentally determine the aggressiveness of evaluation and treatment: 1

Low-risk patients (women <60 years OR men <40 years, never smokers or <10 pack-years, 3-10 RBCs/HPF on single urinalysis):

• May defer some components of evaluation
• Conservative follow-up acceptable if no concerning features develop 1

High-risk patients (age ≥60 years, >30 pack-years smoking, >25 RBCs/HPF, history of gross hematuria, occupational chemical/dye exposure, urologic disorders, irritative voiding symptoms, or recurrent UTIs despite antibiotics):

• Require mandatory full urologic evaluation regardless of other factors 1
• This is non-negotiable even in patients on anticoagulation 1, 2

Distinguishing Glomerular from Non-Glomerular Sources

This distinction is critical because it determines whether the patient needs nephrology versus urology management: 1, 3

Indicators of glomerular disease requiring nephrology referral: 1, 3

• Dysmorphic RBCs >80% on urinary sediment examination
• Red blood cell casts (pathognomonic for glomerular disease)
• Significant proteinuria >500 mg/24 hours
• Elevated serum creatinine or declining renal function
• Associated hypertension

Refer to nephrology immediately if: 1, 3

• Proteinuria >1,000 mg/24 hours
• Proteinuria >500 mg/24 hours that is persistent or increasing
• Dysmorphic RBCs >80% with red cell casts
• Elevated creatinine with hematuria

Treatment Pathways Based on Underlying Cause

For Urologic (Non-Glomerular) Causes:

Malignancy (30-40% of gross hematuria, 2.6-4% of microscopic hematuria): 2, 4

• Bladder cancer, renal cell carcinoma, or transitional cell carcinoma require urgent urologic oncology referral
• Treatment ranges from transurethral resection to nephrectomy to systemic chemotherapy depending on stage
• Never delay evaluation in gross hematuria—30-40% malignancy risk mandates urgent urologic referral even if self-limited 1, 2

Urinary tract infection: 2

• Treat with appropriate antibiotics based on culture and sensitivity
• Repeat urinalysis 6 weeks post-treatment to confirm resolution 1
• If hematuria persists, proceed with full urologic evaluation

Urolithiasis (kidney/ureteral stones): 2, 5

• Conservative management with hydration and analgesia for stones <5mm
• Urologic intervention (lithotripsy, ureteroscopy, or percutaneous nephrolithotomy) for larger or obstructing stones
• Medical expulsive therapy with alpha-blockers for distal ureteral stones

Benign prostatic hyperplasia in men: 2, 4

• Alpha-blockers (tamsulosin, alfuzosin) or 5-alpha reductase inhibitors (finasteride, dutasteride)
• Critical caveat: BPH can cause hematuria but does not exclude concurrent malignancy—gross hematuria from BPH must be proven through appropriate evaluation 2

Trauma: 2

• Gross hematuria after trauma requires contrast-enhanced CT
• Blood at urethral meatus with pelvic fractures requires retrograde urethrography before catheter placement
• Treatment ranges from observation to surgical repair depending on injury grade

For Glomerular/Renal Parenchymal Causes:

Glomerulonephritis (post-infectious, IgA nephropathy): 2

• Supportive care with blood pressure control and proteinuria reduction using ACE inhibitors or ARBs
• Immunosuppression (corticosteroids, cyclophosphamide, mycophenolate) for specific types
• Nephrology manages these conditions

Alport Syndrome: 2

• ACE inhibitors or ARBs to slow progression
• Genetic counseling
• Monitoring for hearing loss and ocular abnormalities

Thin basement membrane nephropathy: 2

• Generally benign, requires only observation
• Monitor blood pressure and renal function annually

Lupus nephritis or vasculitis: 2

• Aggressive immunosuppression with corticosteroids plus cyclophosphamide or mycophenolate
• Requires nephrology and rheumatology co-management

Mandatory Urologic Evaluation Components for High-Risk Patients

All high-risk patients require: 1, 2

1. Multiphasic CT urography (preferred imaging modality for detecting renal cell carcinoma, transitional cell carcinoma, and urolithiasis) 1, 2

2. Cystoscopy (mandatory for all patients ≥40 years with microscopic hematuria and all patients with gross hematuria to detect bladder tumors and carcinoma in situ) 1, 2

3. Urine cytology in high-risk patients to detect urothelial cancers 1

4. Serum creatinine to assess renal function 2

Follow-Up Protocol After Negative Initial Evaluation

If the complete workup is negative but hematuria persists: 1, 3

• Repeat urinalysis at 6,12,24, and 36 months
• Monitor blood pressure at each visit
• Consider comprehensive re-evaluation in 3-5 years if hematuria persists, particularly in high-risk populations 1

Immediate re-evaluation warranted if: 2, 3

• Gross hematuria develops
• Significant increase in degree of microscopic hematuria
• New urologic symptoms appear (irritative voiding, flank pain, dysuria)
• Development of hypertension, proteinuria, or evidence of glomerular bleeding

Critical Pitfalls to Avoid

Never attribute hematuria solely to anticoagulation or antiplatelet therapy—these medications may unmask underlying pathology but do not cause hematuria themselves; evaluation must proceed regardless. 1, 2

Do not delay evaluation in patients with rapid recurrence of UTI with the same organism—this may indicate calculus disease requiring urologic intervention. 1

Maintain equal vigilance across sexes—women are significantly underreferred for hematuria evaluation despite similar cancer risk. 1

Gross hematuria should never be ignored even if self-limited—it carries a 30-40% malignancy risk and requires urgent urologic referral. 1, 2, 4

Do not defer cystoscopy in elderly patients—hematuria can precede bladder cancer diagnosis by many years, making long-term surveillance essential in high-risk elderly patients. 2