What is the appropriate workup for a patient presenting with hematuria, leukocytosis, and a history of smoking and possible occupational exposures?

Workup for Hematuria

For a patient with hematuria, leukocytosis, smoking history, and occupational exposures, you must proceed with complete urologic evaluation including multiphasic CT urography and cystoscopy—this patient is automatically high-risk for malignancy based on age, smoking, and occupational exposure alone. 1, 2

Initial Confirmation and Risk Assessment

Confirm true hematuria first:

• Verify microscopic hematuria with ≥3 RBCs per high-power field on microscopic examination of at least two of three properly collected clean-catch midstream specimens 1, 3
• Dipstick positivity alone is insufficient (only 65-99% specificity) and must be confirmed microscopically 1, 3
• For high-risk patients like this one, even a single specimen with ≥3 RBCs/HPF may warrant full evaluation 2

This patient is definitively high-risk based on:

• Smoking history (>30 pack-years = high risk; 10-30 pack-years = intermediate risk) 1
• Occupational exposure to chemicals/dyes (benzenes, aromatic amines) 1, 2
• Age considerations (males ≥60 years = high risk; 40-59 years = intermediate risk) 1
• Leukocytosis suggests possible infection, but do not attribute hematuria to infection without complete evaluation 1

Critical Rule-Outs Before Proceeding

Exclude urinary tract infection:

• Obtain urine culture preferably before antibiotics 1, 4
• If UTI is present, treat appropriately and repeat urinalysis after treatment 3
• Persistence of hematuria after treating infection mandates full urologic workup—never assume infection explains everything 1, 3

Assess for glomerular disease (to determine if nephrology referral also needed):

• Examine urinary sediment for dysmorphic RBCs (>80% suggests glomerular source) 1, 4
• Look for red blood cell casts (pathognomonic for glomerular disease) 1
• Check for significant proteinuria (protein-to-creatinine ratio >0.2 g/g suggests renal parenchymal disease) 1, 4
• Tea-colored or cola-colored urine suggests glomerular source 1
• If glomerular features present, pursue concurrent nephrology and urology referrals 3

Mandatory Complete Urologic Evaluation

Upper tract imaging:

• Multiphasic CT urography is the preferred modality for detecting renal cell carcinoma, transitional cell carcinoma, and urolithiasis 1, 2, 3
• Must include unenhanced, nephrographic phase, and excretory phase images 1
• If CT contraindicated (renal insufficiency, contrast allergy), use MR urography or renal ultrasound with retrograde pyelography as alternatives 1
• Traditional IVU is acceptable but has limited sensitivity for small renal masses 1

Lower tract evaluation:

• Cystoscopy is mandatory for all high-risk patients to visualize bladder mucosa, urethra, and ureteral orifices 1, 2, 3
• Flexible cystoscopy is preferred over rigid (less pain, equivalent or superior diagnostic accuracy) 1
• Evaluates for bladder transitional cell carcinoma (most frequently diagnosed malignancy in hematuria), urethral stricture disease, and benign prostatic hyperplasia 1, 2

Laboratory evaluation:

• Serum creatinine, BUN, complete metabolic panel 1
• Complete urinalysis with microscopy 1
• Voided urine cytology in high-risk patients (detects high-grade urothelial carcinomas and carcinoma in situ) 1, 2

Critical Pitfalls to Avoid

Never defer evaluation for these reasons:

• Anticoagulation or antiplatelet therapy does not cause hematuria—these medications may only unmask underlying pathology that requires investigation 1, 2
• Benign prostatic hyperplasia can cause hematuria but does not exclude concurrent malignancy 1
• Self-limited gross hematuria still requires full evaluation (30-40% malignancy risk) 1
• Do not prescribe additional antibiotics for persistent hematuria—this delays cancer diagnosis 1

Leukocytosis context:

• The leukocytosis may represent systemic infection, but asymptomatic bacteriuria should not be treated and does not explain hematuria 1
• Pyuria without infection requires hematuria evaluation, not antibiotics 1

Follow-Up Protocol if Initial Workup Negative

If complete evaluation reveals no malignancy or significant pathology:

• Repeat urinalysis, voided urine cytology, and blood pressure at 6,12,24, and 36 months 1, 4
• Immediate re-evaluation warranted if: gross hematuria develops, significant increase in microscopic hematuria, new urologic symptoms, or development of hypertension/proteinuria 1
• Consider nephrology referral if hematuria persists with hypertension, proteinuria, or glomerular bleeding features 1, 4

Malignancy Risk Context

The stakes are high in this patient:

• Gross hematuria carries 30-40% malignancy risk 1
• Microscopic hematuria in high-risk patients carries 2.6-5% malignancy risk 1, 3
• Smoking history >30 pack-years is high risk for urothelial carcinoma 1
• Occupational chemical exposure significantly increases urothelial carcinoma risk 1
• Early detection of urologic malignancy significantly impacts mortality and morbidity 2