What is the appropriate management for a patient with haematuria?

Management of Haematuria

All patients with visible (gross) haematuria require urgent urologic evaluation with cystoscopy and upper tract imaging regardless of whether bleeding is self-limited, as this carries a 30-40% risk of malignancy. 1

Initial Confirmation and Classification

Confirm true haematuria by microscopic urinalysis showing ≥3 red blood cells per high-power field (RBC/HPF) on at least two of three properly collected clean-catch midstream urine specimens before initiating any workup. 1, 2 Dipstick testing alone has limited specificity (65-99%) and produces false positives from myoglobinuria, hemoglobinuria, or menstrual contamination. 2

Distinguish Between Gross and Microscopic Haematuria

• Gross (macroscopic) haematuria: Blood visible to the naked eye, carrying 30-40% malignancy risk and requiring immediate urologic referral. 1
• Microscopic haematuria: ≥3 RBCs/HPF on microscopy only, carrying 2.6-4% overall malignancy risk (higher in risk populations). 3, 1

Exclude Transient Benign Causes First

Before extensive workup, exclude and re-test after resolution of: 2

• Menstruation: Repeat urinalysis 48 hours after cessation. 4
• Vigorous exercise: Repeat urinalysis 48 hours after cessation. 1, 4
• Urinary tract infection: Obtain urine culture before antibiotics, treat appropriately, then repeat urinalysis 6 weeks after treatment completion. 4, 2 If haematuria resolves, no further evaluation needed. 4
• Sexual activity or minor trauma: Repeat urinalysis 48 hours later. 4
• Viral illness: Repeat urinalysis after resolution. 4, 2

Critical pitfall: Never attribute haematuria to anticoagulation or antiplatelet therapy—these medications may unmask underlying pathology but do not cause haematuria themselves, and evaluation must proceed regardless. 1, 2

Determine Glomerular vs Non-Glomerular Source

This distinction determines whether nephrology or urology leads the evaluation. 1

Indicators of Glomerular Disease (Nephrology Referral)

• Dysmorphic RBCs >80% on urinary sediment with phase contrast microscopy. 1, 2
• Red blood cell casts (pathognomonic for glomerular disease). 1
• Significant proteinuria >500 mg/24 hours or protein-to-creatinine ratio >0.5. 1, 2
• Tea-colored or cola-colored urine (suggests glomerular bleeding). 3, 1
• Elevated serum creatinine or declining renal function. 1
• Hypertension accompanying haematuria. 1

If glomerular features present: Refer to nephrology for evaluation of glomerulonephritis, IgA nephropathy, Alport syndrome, or other renal parenchymal disease, but still complete urologic evaluation as malignancy can coexist. 1, 2

Non-Glomerular Haematuria (Urologic Evaluation)

Proceed with risk stratification if: 2

• Normal-appearing RBCs (>80% non-dysmorphic)
• Absent or minimal proteinuria (<500 mg/24 hours)
• Normal renal function
• No red cell casts

Risk Stratification for Urologic Malignancy

The American Urological Association stratifies patients into three categories that determine evaluation intensity: 2

High-Risk Patients (Require Full Urologic Evaluation)

• Age ≥60 years (either sex). 1, 2
• Smoking history >30 pack-years. 1, 2

• 25 RBCs/HPF on single urinalysis. 2

• Any history of gross haematuria (even if currently microscopic). 1, 2
• Occupational exposure to chemicals/dyes (benzenes, aromatic amines). 1, 4, 2
• History of urologic disorders or pelvic irradiation. 3, 4
• Irritative voiding symptoms (urgency, frequency, nocturia) without infection. 1, 2
• Analgesic abuse or chronic indwelling foreign body. 3, 4

Intermediate-Risk Patients (Shared Decision-Making)

• Women age 50-59 years or men age 40-59 years. 2
• Smoking history 10-30 pack-years. 2
• 11-25 RBCs/HPF on single urinalysis. 2

Low-Risk Patients (May Defer Extensive Workup)

• Women age <50 years or men age <40 years. 2
• Never smoker or <10 pack-years. 2
• 3-10 RBCs/HPF on single urinalysis. 2
• No additional risk factors. 2

Complete Urologic Evaluation for High-Risk and Gross Haematuria

Upper Tract Imaging

Multiphasic CT urography is the preferred imaging modality, including unenhanced, nephrographic phase, and excretory phase images to detect renal cell carcinoma, transitional cell carcinoma, and urolithiasis. 3, 1, 2 This is mandatory for all high-risk patients and anyone with gross haematuria. 1

Alternatives if CT contraindicated: MR urography or renal ultrasound with retrograde pyelography for patients with renal insufficiency or contrast allergy, though these are less optimal. 1

Lower Tract Evaluation

Flexible cystoscopy is mandatory for all patients ≥40 years with microscopic haematuria and all patients with gross haematuria to visualize bladder mucosa, urethra, and ureteral orifices. 1, 2 Flexible cystoscopy is preferred over rigid as it causes less pain with equivalent or superior diagnostic accuracy. 1

Additional Testing

• Voided urine cytology in high-risk patients to detect high-grade urothelial carcinomas and carcinoma in situ. 1, 2
• Serum creatinine to assess renal function. 1, 4
• Complete urinalysis with microscopy to examine for dysmorphic RBCs and casts. 1

Management of Low-Risk Microscopic Haematuria

For patients without risk factors and confirmed non-glomerular microscopic haematuria: 2

• Option 1: Repeat urinalysis in 6 months; if resolved, no further workup. 2
• Option 2: Proceed with evaluation based on patient preference and shared decision-making. 2

Follow-Up Protocol After Negative Initial Evaluation

If complete workup is negative but haematuria persists: 1, 2

• Repeat urinalysis at 6,12,24, and 36 months. 1, 2
• Monitor blood pressure at each visit. 1, 2
• Consider comprehensive re-evaluation within 3-5 years if haematuria persists, particularly in high-risk populations. 1, 2
• After two consecutive negative annual urinalyses, no further testing for asymptomatic microhaematuria is necessary. 1

Immediate Re-Evaluation Warranted If:

• Gross haematuria develops. 1, 2
• Significant increase in degree of microscopic haematuria. 1, 2
• New urologic symptoms appear (dysuria, flank pain, irritative voiding). 1, 2
• Development of hypertension, proteinuria, or evidence of glomerular bleeding. 1, 2

Special Populations

Paediatric Patients

• Children with isolated microscopic haematuria without proteinuria or dysmorphic RBCs do not require imaging—clinical follow-up is appropriate. 3, 1
• Gross haematuria in children requires renal and bladder ultrasound to exclude nephrolithiasis, anatomic abnormalities, and rarely tumours. 1
• CT is not appropriate for initial evaluation of isolated nonpainful, nontraumatic haematuria in children. 1

Elderly Males

Males ≥60 years are automatically high-risk and require full urologic evaluation with cystoscopy and CT urography regardless of other factors. 1 Benign prostatic hyperplasia can cause haematuria but does not exclude concurrent malignancy—gross haematuria from BPH must be proven through appropriate evaluation. 1

Critical Pitfalls to Avoid

• Never ignore gross haematuria, even if self-limited—30-40% malignancy risk mandates urgent urologic referral. 1, 2
• Do not defer evaluation due to anticoagulation—these medications unmask but do not cause haematuria. 1, 2
• Do not rely solely on dipstick testing—confirm with microscopic urinalysis showing ≥3 RBCs/HPF. 1, 2
• Do not prescribe empiric antibiotics for haematuria without documented infection, as this delays cancer diagnosis. 1
• Do not stop at symptom resolution—documented microscopic confirmation of haematuria resolution is required. 4
• Delays beyond 9 months from first haematuria presentation are associated with worse cancer-specific survival in bladder cancer patients. 1