What is the appropriate evaluation and management for a patient with mild hematuria and intermittent mild coccyx pain?

Evaluation and Management of Mild Hematuria with Intermittent Coccyx Pain

This patient requires confirmation of true hematuria with microscopic urinalysis showing ≥3 RBCs per high-power field, followed by risk stratification and complete urologic evaluation if confirmed, while the coccyx pain should be evaluated separately as it is unlikely to be related to the hematuria. 1

Initial Confirmation of Hematuria

• Obtain microscopic urinalysis to confirm ≥3 RBCs/HPF before initiating any workup, as dipstick testing has only 65-99% specificity and can produce false positives from food substances, medications, menstruation, or vigorous exercise 1, 2
• Repeat urinalysis on at least two of three properly collected clean-catch midstream specimens to confirm persistent hematuria 1
• Exclude benign transient causes by repeating urinalysis 48 hours after cessation of vigorous exercise, sexual activity, or menstruation 2

Risk Stratification Using 2025 AUA/SUFU Criteria

Once true hematuria is confirmed, stratify the patient based on:

• Age and sex: Males ≥60 years are high-risk (1.3-6.3% malignancy risk), males 40-59 years are intermediate-risk (0.2-3.1%), and males <40 years are low-risk (0-0.4%) 1, 2
• Smoking history: >30 pack-years is high-risk, 10-30 pack-years is intermediate-risk, and <10 pack-years or never smoker is low-risk 1
• Degree of hematuria: >25 RBCs/HPF increases risk category 1
• History of gross hematuria: Any prior episode of visible blood automatically elevates risk and requires full evaluation 1, 2
• Occupational exposures: Benzenes, aromatic amines, or chemical/dye exposure increases malignancy risk 1, 2

Distinguish Glomerular from Non-Glomerular Sources

• Examine urinary sediment for dysmorphic RBCs (>80% suggests glomerular disease) and red blood cell casts (pathognomonic for glomerular disease) 1
• Check for proteinuria: Significant proteinuria (protein-to-creatinine ratio >0.2 g/g) with hematuria strongly suggests glomerular origin 1
• Assess urine color: Tea-colored or cola-colored urine indicates glomerular disease, while bright red suggests lower urinary tract bleeding 1
• Obtain serum creatinine, BUN, and complete metabolic panel to evaluate renal function 1

Complete Urologic Evaluation for Intermediate or High-Risk Patients

For patients with non-glomerular hematuria and intermediate or high-risk features:

• Multiphasic CT urography is the preferred imaging modality to detect renal cell carcinoma, transitional cell carcinoma, and urolithiasis (includes unenhanced, nephrographic, and excretory phases) 1, 2
• Cystoscopy is mandatory to visualize bladder mucosa, urethra, and ureteral orifices and exclude bladder cancer (flexible cystoscopy preferred over rigid due to less pain and equivalent diagnostic accuracy) 1, 2
• Voided urine cytology should be obtained in high-risk patients to detect high-grade urothelial carcinomas 1, 2
• Urine culture if infection is suspected, preferably before starting antibiotics 1

Nephrology Referral Indications

Refer to nephrology if any of the following are present:

• Dysmorphic RBCs >80% or red blood cell casts 1
• Significant proteinuria (protein-to-creatinine ratio >0.2 g/g) 1
• Elevated serum creatinine or declining renal function 1
• Hypertension accompanying hematuria 1
• Tea-colored urine suggesting glomerular disease 1

Evaluation of Coccyx Pain

The coccyx pain is anatomically and pathophysiologically unrelated to hematuria and requires separate evaluation:

• Coccyx pain (coccydynia) is typically caused by trauma, prolonged sitting, childbirth, or idiopathic inflammation and does not cause hematuria 1
• Physical examination should include pelvic examination in women and rectal examination in men to exclude gynecologic and prostate causes of pelvic pain 2
• Consider interstitial cystitis if the patient has chronic pelvic/bladder pain with irritative voiding symptoms (urgency, frequency, nocturia), as this can present with hematuria and pelvic pain 2, 3, 4
• If interstitial cystitis is suspected, cystoscopy is essential to identify Hunner lesions (diagnostic for IC) and exclude bladder cancer 3, 4

Follow-Up Protocol if Initial Evaluation is Negative

• Repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring at each visit 1, 2
• Immediate re-evaluation is warranted if gross hematuria develops, significant increase in microscopic hematuria occurs, new urologic symptoms appear, or development of hypertension/proteinuria 1
• After two consecutive negative annual urinalyses, no further testing for asymptomatic microhematuria is necessary 1

Critical Pitfalls to Avoid

• Never ignore gross hematuria, even if self-limited, as it carries a 30-40% malignancy risk and mandates urgent urologic referral 1, 2
• Do not attribute hematuria to anticoagulation or antiplatelet therapy—these medications may unmask underlying pathology but do not cause hematuria themselves, and evaluation should proceed regardless 1, 2
• Do not rely solely on dipstick testing—always confirm with microscopic urinalysis showing ≥3 RBCs/HPF before initiating workup 1, 2
• Do not assume the coccyx pain explains the hematuria—these are separate issues requiring independent evaluation 1
• Do not skip cystoscopy in intermediate or high-risk patients, as bladder cancer can only be definitively excluded through direct visualization 1, 2, 3