What could be causing the feeling of pressure when urinating, with the presence of red blood cells (RBC) and epithelial squamous cells in the urine?

Evaluation of Pressure During Urination with RBCs and Squamous Epithelial Cells

The most likely diagnosis is a urinary tract infection (UTI), which should be confirmed with urine culture before initiating antibiotic therapy, though the presence of RBCs warrants complete evaluation for hematuria once the infection is treated. 1

Initial Assessment and Interpretation

The combination of pressure during urination (dysuria) with RBCs in urine represents symptomatic hematuria that requires systematic evaluation. However, the presence of squamous epithelial cells requires careful interpretation:

• Squamous epithelial cells do NOT indicate bacterial contamination - studies show they are present in 94% of catheterized samples from women without any contamination, and their presence in midstream samples predicts contamination in only 21% of cases 2
• The squamous cells are likely from the urethra, trigone area of the bladder, or cervicovaginal region in women, and represent normal shedding rather than pathology 1, 3
• Do not dismiss the hematuria based on squamous cell presence - the RBCs require evaluation regardless of squamous cells 4

Immediate Diagnostic Steps

Confirm True Hematuria

• Verify ≥3 RBCs per high-power field on microscopic examination of properly collected urine specimens 1, 5
• If dipstick positive only, confirm with microscopic analysis before proceeding with extensive workup 1

Evaluate for Urinary Tract Infection

• Obtain urine culture BEFORE starting antibiotics if UTI is suspected based on dysuria, urgency, frequency, or fever 1
• The pressure sensation during urination strongly suggests lower urinary tract pathology, most commonly infection 1
• If UTI is confirmed, treat appropriately and repeat urinalysis 6 weeks after treatment completion to ensure hematuria resolves 5

Risk Stratification for Underlying Pathology

Even with suspected UTI, assess for high-risk features that would mandate complete urologic evaluation:

High-Risk Features Requiring Full Workup 1, 5

• Age >35-40 years (especially >60 years)
• Any history of gross hematuria
• Smoking history (especially >30 pack-years)
• Occupational exposure to chemicals/dyes (benzenes, aromatic amines)
• Irritative voiding symptoms without infection
• Male gender
• History of pelvic irradiation

Glomerular Disease Indicators 1, 5

• Tea-colored or cola-colored urine (not bright red)
• Significant proteinuria (>1g/day or protein-to-creatinine ratio >0.2)
• Elevated serum creatinine or declining renal function
• Hypertension accompanying hematuria

Complete Evaluation Pathway

If UTI is Confirmed

1. Treat infection with appropriate antibiotics 5
2. Repeat urinalysis 6 weeks post-treatment 5
3. If hematuria persists (≥3 RBCs/HPF), proceed with complete urologic evaluation 1

If No Infection or Hematuria Persists After Treatment

For patients with risk factors or persistent hematuria: 1, 5

• Upper tract imaging: Multiphasic CT urography is preferred to detect renal cell carcinoma, transitional cell carcinoma, and urolithiasis 1
• Cystoscopy: Mandatory for all patients ≥35 years old or younger patients with risk factors 5
• Renal function tests: Serum creatinine, eGFR, BUN 5, 6
• Assess for proteinuria: Spot urine protein-to-creatinine ratio 1, 6

If glomerular features present (dysmorphic RBCs >80%, RBC casts, significant proteinuria, elevated creatinine): 1, 5

• Concurrent nephrology referral in addition to completing urologic evaluation
• Both evaluations must be completed as malignancy can coexist with glomerular disease 1

Critical Pitfalls to Avoid

• Never attribute hematuria solely to anticoagulation or antiplatelet therapy - these medications may unmask underlying pathology but do not cause hematuria 1, 5
• Do not ignore persistent hematuria after UTI treatment - 30-40% of gross hematuria cases are associated with malignancy 1
• Do not delay evaluation beyond 2 months - persistent symptoms despite appropriate antibiotic therapy effectively rule out simple UTI and strongly suggest non-infectious etiology such as malignancy 1
• Squamous cells are not a reason to dismiss the findings - they do not reliably predict contamination and should not defer proper evaluation 2, 4, 7

Follow-Up Protocol

If initial complete evaluation is negative but hematuria persists: 1, 5

• Repeat urinalysis at 6,12,24, and 36 months
• Monitor blood pressure at each visit
• Assess for proteinuria development
• Consider repeat complete evaluation within 3-5 years for high-risk patients
• Immediate re-evaluation if gross hematuria develops, significant increase in microscopic hematuria, or new urologic symptoms appear