What is the best course of action for an elderly patient presenting with hematuria, mild low back pain, and suprapubic tenderness, with a history of kidney stones and sepsis, who is hemodynamically stable with no fever or vomiting?

Recommended Tests and Management Plan for Elderly Patient with Hematuria

This patient requires urgent urinalysis with microscopy, urine culture, complete blood count, serum creatinine, and CT urography, followed by same-day or next-day urology referral for cystoscopy. 1, 2

Immediate Diagnostic Testing in Urgent Care

Laboratory Studies

• Urinalysis with microscopy to confirm hematuria (≥3 RBCs/HPF), assess for pyuria, and evaluate for dysmorphic RBCs or casts that would suggest glomerular disease 3, 1
• Urine culture to definitively rule out urinary tract infection, even though the patient lacks fever—elderly patients may not mount typical inflammatory responses 3
• Complete blood count with differential to assess for leukocytosis (≥14,000 cells/mm³) or left shift (≥16% bands), which would indicate bacterial infection requiring more aggressive management 3
• Serum creatinine and BUN to evaluate renal function, as the history of kidney stones and prior sepsis places this patient at risk for chronic kidney disease 1, 4, 2

Critical Risk Stratification

This elderly patient is automatically high-risk for urologic malignancy based on age alone, with gross hematuria carrying a 30-40% malignancy risk 1, 2. The combination of visible hematuria, suprapubic tenderness, and history of kidney stones creates diagnostic urgency even without fever or hemodynamic instability 1, 2.

Imaging Decision

CT urography (multiphasic CT abdomen/pelvis with IV contrast) is the mandatory imaging study for this patient and should be ordered from urgent care if available, or arranged urgently through urology referral 1, 4, 2. This imaging modality will:

• Detect urolithiasis (given her history of kidney stones) 1, 5
• Identify renal cell carcinoma or transitional cell carcinoma 1, 2
• Evaluate for hydronephrosis or obstruction 3
• Assess for less common causes like subcapsular hematoma (Page kidney) 6

Do not order renal ultrasound alone—it is insufficient for comprehensive upper tract evaluation in a high-risk patient with hematuria 1, 4.

Infection Management Considerations

When to Treat Empirically

If the urinalysis shows pyuria (≥10 WBCs/HPF) AND the patient develops fever, hypotension, or altered mental status, initiate empiric antibiotics immediately for suspected urosepsis while awaiting culture results 3. However, do not prescribe antibiotics for asymptomatic bacteriuria or pyuria alone—this delays cancer diagnosis and promotes antibiotic resistance 1.

Critical Distinction

The absence of CVA tenderness does NOT rule out serious pathology in elderly patients, who may have atypical presentations of both infection and malignancy 3. Suprapubic tenderness with hematuria suggests lower urinary tract pathology requiring cystoscopic evaluation 1, 2.

Urgent Urology Referral

Arrange urology consultation within 24-48 hours for cystoscopy, which is mandatory for all patients with gross hematuria regardless of age or other findings 1, 4, 2. The urologist will:

• Perform flexible cystoscopy to visualize bladder mucosa and exclude transitional cell carcinoma 1, 2
• Obtain voided urine cytology if not already done 1, 2
• Coordinate definitive management based on imaging and cystoscopy findings 1, 2

Common Pitfalls to Avoid

Do not delay urologic evaluation even if:

• The hematuria resolves spontaneously—30-40% of gross hematuria cases harbor malignancy 1, 2
• A urinary tract infection is identified and treated—repeat urinalysis 6 weeks post-treatment is mandatory to confirm hematuria resolution 4
• The patient's history of kidney stones seems to explain the symptoms—stones and cancer can coexist 1, 5

Do not attribute hematuria to:

• Anticoagulation or antiplatelet medications (if applicable)—these may unmask underlying pathology but do not cause hematuria 1, 4
• Age-related "benign" changes—elderly patients have the highest risk of urologic malignancy 1, 2

Disposition from Urgent Care

Safe for discharge home if:

• Vital signs remain stable 3
• No signs of sepsis develop (fever, hypotension, altered mental status) 3
• Patient can tolerate oral intake 3
• Reliable follow-up with urology is confirmed within 24-48 hours 1, 2

Requires emergency department transfer if:

• Fever develops (≥100°F oral or ≥2°F increase from baseline) 3
• Hemodynamic instability occurs 3
• Acute urinary retention develops 3
• Severe pain uncontrolled with oral analgesics 5

Nephrology Referral Considerations

Consider nephrology consultation if urinalysis reveals:

• Dysmorphic RBCs >80% or red cell casts (suggests glomerular disease) 1, 4
• Significant proteinuria (protein-to-creatinine ratio >0.2) 1, 4
• Elevated creatinine with evidence of declining renal function 1, 4

However, complete the urologic evaluation first—even glomerular-appearing hematuria requires exclusion of malignancy in high-risk patients 1, 4.