What should a middle-aged adult with no prior medical history do if they experience hematuria?

Blood in Urine: Immediate Action Required

If you can see blood in your urine with your naked eye (gross hematuria), you must see a urologist urgently—even if the bleeding stops on its own—because the cancer risk exceeds 10% and can be as high as 30-40%. 1

What You Need to Do First

Confirm True Blood in Urine

• If you haven't actually seen red/pink urine but had a positive dipstick test at a clinic, you need microscopic urinalysis showing ≥3 red blood cells per high-powered field before any further workup 1
• Dipstick tests alone have only 65-99% accuracy and can give false positives from foods, medications, or menstrual contamination 2

Immediate Urologist Referral Required If:

• Any visible blood in urine (gross hematuria)—this is mandatory regardless of whether bleeding stopped 1, 3, 4
• Microscopic hematuria confirmed (≥3 RBCs/HPF) without an obvious benign cause like urinary tract infection 1, 3

Why This Matters

Gross hematuria carries a 30-40% risk of cancer in adults, while microscopic hematuria carries a 0.5-5% overall risk but 7-20% in higher-risk groups. 1, 2 The most common cancers found are bladder cancer, kidney cancer, and upper urinary tract cancers 2.

Risk Factors That Increase Cancer Likelihood:

• Age over 35-40 years (especially males ≥60 years) 2, 4
• Smoking history, particularly >30 pack-years 2
• Occupational exposure to chemicals/dyes (benzenes, aromatic amines) 2, 4
• Irritative urinary symptoms (urgency, frequency) without infection 2
• History of prior gross hematuria episodes 2

What the Urologist Will Do

The complete evaluation includes 3, 2, 4:

Imaging:

• CT urography (CT scan with contrast) is the preferred test to detect kidney cancer, bladder cancer, and stones 2, 4
• This involves unenhanced, nephrographic, and excretory phase images to comprehensively evaluate your entire urinary tract 2

Cystoscopy:

• Direct visualization of your bladder with a flexible scope (causes minimal discomfort) 3, 2
• This is mandatory for all gross hematuria and most microscopic hematuria cases because imaging alone can miss bladder cancer 3, 2

Critical Pitfalls to Avoid

Do NOT Delay Evaluation If:

• You take blood thinners (aspirin, warfarin, Plavix, etc.)—these medications don't cause hematuria, they only unmask underlying problems that need investigation 1, 3, 2
• The bleeding stopped on its own—self-limited gross hematuria still requires full evaluation 1, 3
• You think it might be a urinary tract infection—gross hematuria should never be assumed to be from infection alone without complete workup 2

What NOT to Do:

• Don't accept urine cytology or molecular markers as initial tests—these are not recommended for initial evaluation 1
• Don't accept "watchful waiting" for gross hematuria—this delays cancer diagnosis 2
• Don't assume your symptoms are medication-related without excluding structural or malignant causes 3

When Kidney Disease (Not Cancer) Might Be the Cause

Consider nephrology referral in addition to completing urologic evaluation if you have 2, 4:

• Tea-colored or cola-colored urine (suggests kidney inflammation) 2, 4
• Significant protein in urine (>2+ on dipstick) 2, 4
• Elevated creatinine (kidney function impairment) 2, 4
• High blood pressure accompanying the hematuria 4

Important: Having kidney disease features does NOT eliminate the need for cancer evaluation—both evaluations must be completed because malignancy can coexist with kidney disease. 4

If Initial Workup Is Negative

Even with negative cystoscopy and imaging, you need 2, 4:

• Repeat urinalysis at 6,12,24, and 36 months 2, 4
• Blood pressure monitoring at each visit 2, 4
• Immediate re-evaluation if gross hematuria recurs, microscopic hematuria worsens significantly, or new urinary symptoms develop 2, 4

Bladder cancer can be diagnosed years after initial hematuria presentation, making long-term surveillance essential in middle-aged and older adults. 2

Bottom Line for a Middle-Aged Adult

See a urologist immediately for any visible blood in urine—this is not optional. 1, 3, 4 The evaluation will include CT imaging and cystoscopy to exclude cancer, which is present in 10-40% of cases depending on your specific risk factors 1, 2. Do not delay this evaluation for any reason, including blood thinner use, self-resolution of bleeding, or suspected infection 1, 3, 2.