What is the best course of action for a patient with urinary pain and hematuria, with a urinalysis showing +2 blood on dipstick?

Evaluation and Management of Urinary Pain with Hematuria

For a patient presenting with urinary pain and +2 blood on urine dipstick, you must first confirm true hematuria with microscopic urinalysis showing ≥3 RBCs per high-power field, then pursue urgent evaluation for urolithiasis or urinary tract infection while simultaneously risk-stratifying for malignancy based on age, smoking history, and other risk factors. 1

Immediate Confirmation and Initial Assessment

• Do not proceed with extensive workup based solely on dipstick results, as dipstick testing has only 65-99% specificity and can produce false positives 1, 2
• Obtain microscopic urinalysis on at least two of three properly collected clean-catch midstream specimens to confirm ≥3 RBCs/HPF 1, 2
• The combination of pain with hematuria strongly suggests urolithiasis (kidney stones) or urinary tract infection as the most likely etiologies, rather than malignancy which typically presents with painless hematuria 3, 4

Distinguish Between Infectious and Non-Infectious Causes

If Infection is Suspected:

• Look for dysuria, urgency, frequency, fever, and suprapubic tenderness on examination 1
• Check for white blood cells, bacteria, and nitrites on urinalysis 3
• Obtain urine culture before initiating antibiotics to guide appropriate therapy 1
• Important caveat: Even if UTI is confirmed, persistent hematuria after appropriate antibiotic treatment (>2 months) effectively rules out simple infection as the sole cause and mandates full urologic evaluation 1

If Urolithiasis is Suspected:

• Flank pain radiating to the groin with colicky characteristics suggests stone disease 1
• Non-contrast CT scan (CT KUB) is the gold standard for detecting urinary stones, with superior sensitivity compared to ultrasound (59% sensitivity for plain radiography) 5
• Ultrasound has limited sensitivity for ureteral stones (only 38% detection rate for stones within the ureter) but may be useful as initial imaging in certain populations 5

Risk Stratification for Malignancy

Even with painful hematuria, you must assess malignancy risk factors that would mandate complete urologic evaluation:

High-Risk Features Requiring Full Workup:

• Age ≥40 years (males ≥60 years are highest risk) 1, 3
• Smoking history >30 pack-years 1
• Occupational exposure to benzenes, aromatic amines, or other chemicals/dyes 1, 3
• History of gross hematuria (even if currently microscopic) 1
• Irritative voiding symptoms (urgency, frequency, nocturia) without infection 1

If High-Risk Features Present:

• CT urography (multiphasic) is the preferred imaging modality to detect renal cell carcinoma, transitional cell carcinoma, and urolithiasis 1, 2
• Cystoscopy is mandatory for all patients ≥40 years with confirmed hematuria, regardless of pain 1, 2
• Voided urine cytology should be obtained in high-risk patients to detect high-grade urothelial carcinomas 1

Laboratory Evaluation

• Serum creatinine, BUN, and complete metabolic panel to assess renal function 1, 3
• Examine urinary sediment for dysmorphic RBCs (>80% suggests glomerular disease) and red cell casts 1
• Check for proteinuria: significant proteinuria (>500 mg/24 hours or protein-to-creatinine ratio >0.2) suggests renal parenchymal disease and warrants nephrology referral 1

Critical Clinical Pearls and Pitfalls

• Never attribute hematuria to anticoagulation or antiplatelet therapy alone—these medications may unmask underlying pathology but do not cause hematuria, and evaluation must proceed regardless 1, 2
• Gross hematuria carries a 30-40% malignancy risk and requires urgent urologic referral even if self-limited or pain is present 1, 3
• Tea-colored or cola-colored urine suggests glomerular disease rather than urologic causes and requires nephrology evaluation in addition to urologic workup 1, 3
• Do not delay urologic evaluation while treating presumed UTI—if hematuria persists after appropriate antibiotic therapy, immediate referral is mandatory 1

Follow-Up Protocol if Initial Workup 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
• Consider nephrology referral if hematuria persists with development of hypertension, proteinuria, or evidence of glomerular bleeding (dysmorphic RBCs, red cell casts) 1, 2

Special Considerations for Pediatric Patients

• In children, ultrasound is the preferred initial imaging modality rather than CT to minimize radiation exposure 5
• Isolated microscopic hematuria without proteinuria or dysmorphic RBCs in children does not require imaging and can be managed with clinical follow-up 5, 1
• Gross hematuria in children requires renal and bladder ultrasound to exclude nephrolithiasis, anatomic abnormalities, and rarely tumors 1