What to Do If You Have Bloody Urine (Hematuria)
If you can see blood in your urine with the naked eye (gross hematuria), you need urgent urologic evaluation immediately—even if it stops on its own—because the risk of cancer exceeds 10-30%. 1, 2, 3
Immediate Actions Required
For Visible Blood (Gross Hematuria)
- Seek urgent urologic referral within days, not weeks 1, 2, 3
- Do not wait to see if it resolves—30-40% of gross hematuria cases are associated with malignancy 1
- This evaluation is mandatory regardless of whether you take blood thinners or have other explanations like prostate enlargement 1, 2, 3
For Microscopic Hematuria (Blood Only Visible Under Microscope)
- First, confirm it's real hematuria: Request microscopic urinalysis showing ≥3 red blood cells per high-power field on at least 2 of 3 properly collected urine samples 1, 2
- Dipstick tests alone are insufficient (only 65-99% specific) and can give false positives 1
- If confirmed and you have ANY of these high-risk features, proceed to full urologic evaluation 1:
- Age >35-40 years (especially males ≥60 years)
- Smoking history (especially >30 pack-years)
- History of ever seeing blood in urine before
- Occupational exposure to chemicals/dyes (benzenes, aromatic amines)
- Irritative urinary symptoms (urgency, frequency) without infection
Required Diagnostic Workup
Initial Testing Before Specialist Referral
- Urine culture to exclude infection (but don't assume infection explains gross hematuria without follow-up) 1, 3
- Serum creatinine to assess kidney function 1, 3
- Microscopic urinalysis to look for protein, casts, and dysmorphic red blood cells that suggest kidney disease 1
Complete Urologic Evaluation (What the Specialist Will Do)
- Multiphasic CT urography (preferred imaging) to detect kidney cancer, bladder cancer, and stones 1, 4
- Cystoscopy (camera examination of bladder) is mandatory for all gross hematuria and high-risk microscopic hematuria 1, 3
- Do NOT obtain urine cytology or molecular markers in initial evaluation—not recommended by current guidelines 1
Critical Pitfalls to Avoid
Never Attribute Hematuria to These Factors Alone
- Blood thinners (anticoagulants/antiplatelet drugs): These medications may unmask underlying pathology but do not cause hematuria—full evaluation is still required 1, 2, 3
- Benign prostate enlargement: This can cause bleeding but does not exclude concurrent cancer 1
- Medications like Cialis: Not a known cause of hematuria and should never be blamed without investigation 1
When to Suspect Kidney Disease Instead of Urologic Cancer
Consider nephrology referral if you have 1:
- Tea-colored or cola-colored urine (suggests glomerular bleeding)
- Significant protein in urine (protein-to-creatinine ratio >0.2)
- Elevated creatinine or declining kidney function
80% dysmorphic red blood cells or red cell casts on microscopy
- New hypertension with hematuria
Follow-Up If Initial Workup Is Negative
If comprehensive evaluation finds no cause but microscopic hematuria persists 1:
- Repeat urinalysis at 6,12,24, and 36 months
- Check blood pressure at each visit
- Immediate re-evaluation if:
- Gross hematuria develops
- Significant increase in microscopic hematuria
- New urinary symptoms appear
- Development of hypertension or protein in urine
Special Considerations
Age-Specific Risk Stratification
- Males ≥60 years: High-risk—require cystoscopy and CT urography regardless of other factors 1
- Males 40-59 years: Intermediate-risk—shared decision-making about extent of workup 1
- Females ≥60 years: Intermediate-risk 1
Benign Causes That May Explain Transient Hematuria
- Vigorous exercise (transient) 1
- Menstrual contamination in women 1
- Recent urinary tract infection (but confirm resolution with repeat urinalysis) 1
- Recent trauma 1
However, even if a benign cause is identified, patients with risk factors or gross hematuria still require full urologic evaluation. 1, 3