What to do if a patient presents with hematuria?

Management of Hematuria

All patients with gross hematuria require immediate urologic referral for cystoscopy and imaging regardless of whether the bleeding is self-limited, as the malignancy risk exceeds 30-40%. 1, 2, 3

Initial Confirmation and Classification

Confirm True Hematuria

• Verify microscopic hematuria with ≥3 red blood cells per high-powered field on microscopic examination before initiating any workup, as dipstick testing has limited specificity (65-99%) and can produce false positives 1, 3, 4
• Obtain at least two of three properly collected clean-catch midstream urine specimens to confirm persistent microscopic hematuria 1, 3
• Rule out factitious causes including menstruation, vigorous exercise, food substances, or medications that color urine without actual red blood cells 1, 3

Distinguish Glomerular from Non-Glomerular Sources

• Examine urinary sediment for dysmorphic red blood cells (>80% suggests glomerular disease) and red blood cell casts (pathognomonic for glomerular disease) using phase contrast microscopy 1, 3
• Tea-colored or cola-colored urine strongly suggests glomerular hematuria (e.g., glomerulonephritis), while bright red blood indicates lower urinary tract bleeding 1, 3
• Check for proteinuria: >2+ on dipstick with hematuria indicates glomerular source 1

Risk Stratification for Malignancy

Gross Hematuria (Visible Blood)

• All patients with gross hematuria are automatically high-risk and require urgent complete urologic evaluation with cystoscopy and upper tract imaging, even if self-limited 1, 2, 3
• Gross hematuria carries a 30-40% malignancy risk in referral series 1, 3

Microscopic Hematuria Risk Factors

High-risk features requiring full urologic evaluation: 1, 2, 3

• Age: Males ≥60 years, females ≥60 years
• Smoking history >30 pack-years
• Occupational exposure to chemicals/dyes (benzenes, aromatic amines)
• History of prior gross hematuria
• Irritative voiding symptoms (urgency, frequency, nocturia) without infection

Intermediate-risk features: 2, 3

• Age: Males 40-59 years, females with any risk factors
• Smoking history 10-30 pack-years
• Hematuria 11-25 RBCs/HPF

Low-risk features: 2, 3

• Age: Males <40 years, females <60 years without risk factors
• Never smoker or <10 pack-years
• Hematuria 3-10 RBCs/HPF

Complete Urologic Evaluation (For High/Intermediate Risk or Gross Hematuria)

Upper Tract Imaging

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

Lower Tract Evaluation

• Cystoscopy is mandatory for all patients with gross hematuria and for microscopic hematuria patients with risk factors to visualize bladder mucosa, urethra, and ureteral orifices 1, 2, 3
• Flexible cystoscopy is preferred over rigid cystoscopy as it causes less pain with equivalent or superior diagnostic accuracy 3
• Do not omit cystoscopy based on negative imaging alone, as it is essential for detecting bladder transitional cell carcinoma 2, 3

Laboratory Testing

• Serum creatinine, BUN, and complete metabolic panel to assess renal function 1, 3
• Complete blood count with platelets to evaluate for coagulopathy 1
• Urine culture if infection suspected (preferably before antibiotics) 1, 3
• Do not obtain urinary cytology or urine-based molecular markers in the initial evaluation per current guidelines 1, 2

Glomerular Hematuria Workup (If Dysmorphic RBCs or Proteinuria Present)

Additional Testing

• Spot urine protein-to-creatinine ratio (normal <0.2 g/g) 3
• Complement levels (C3, C4) to evaluate for post-infectious glomerulonephritis or lupus nephritis 3
• Antinuclear antibody (ANA) and ANCA testing if vasculitis suspected 3
• Evaluation for hypercalciuria (spot urine calcium-to-creatinine ratio) 1
• Audiogram and slit lamp examination if Alport syndrome suspected 1, 3

Nephrology Referral Indications

• Persistent significant proteinuria (protein-to-creatinine ratio >0.2 for three specimens) 3
• Presence of red cell casts or >80% dysmorphic RBCs 3
• Elevated creatinine or declining renal function 3
• Hypertension with hematuria and proteinuria 3
• eGFR <30 mL/min/1.73 m² 2

Special Populations and Considerations

Pediatric Patients

• Children with isolated microscopic hematuria without proteinuria or dysmorphic RBCs do not require imaging, as they are unlikely to have clinically significant renal disease 1
• Renal ultrasound is the preferred modality in children to assess anatomy before potential renal biopsy 1, 3
• Screen family members' urine for benign familial hematuria or thin basement membrane nephropathy 1

Patients on Anticoagulation/Antiplatelet Therapy

• Pursue full evaluation regardless of anticoagulation or antiplatelet therapy, as these medications unmask but do not cause hematuria 1, 2, 3
• Do not delay or defer urologic referral based on medication use 1, 2

Post-Traumatic Hematuria

• Macroscopic hematuria after trauma requires contrast-enhanced CT to identify extent of renal or urinary tract injury 1, 3
• Blood at urethral meatus with pelvic fractures or straddle injury requires retrograde urethrography before catheter placement 3
• Isolated microscopic hematuria without clinical findings of visceral trauma does not need emergency investigation 3

Follow-Up Protocol for Negative Initial Evaluation

Surveillance Schedule

• Repeat urinalysis, blood pressure measurement at 6,12,24, and 36 months if initial workup negative but hematuria persists 1, 3
• Consider voided urine cytology at follow-up visits for high-risk patients 3

Indications for Immediate Re-evaluation

• Recurrent gross hematuria 3
• Significant increase in degree of microscopic hematuria 3
• New urologic symptoms (flank pain, dysuria, irritative voiding symptoms) 3
• Development of hypertension, proteinuria, or evidence of glomerular bleeding 3

Critical Pitfalls to Avoid

• Never attribute hematuria solely to anticoagulation—full urologic evaluation is mandatory 1, 2, 3
• Never ignore gross hematuria, even if painless or self-limited—30-40% malignancy risk mandates urgent referral 1, 2, 3
• Never delay evaluation for urinary tract infection treatment—persistent hematuria after appropriate antibiotics requires full workup 3
• Never assume benign prostatic hyperplasia explains hematuria without excluding concurrent malignancy 3
• Never use screening urinalysis for cancer detection in asymptomatic adults 1
• Do not treat asymptomatic bacteriuria with pyuria and hematuria—this represents hematuria requiring urologic evaluation, not infection 3, 4