What is the appropriate workup and management for an elderly patient presenting with hematuria (blood in urine)?

Hematuria Workup in Elderly Patients

Elderly patients with hematuria require urgent and complete urologic evaluation with multiphasic CT urography and cystoscopy, regardless of whether the hematuria is gross or microscopic, because age ≥60 years automatically places them at high risk for malignancy (30-40% risk with gross hematuria). 1

Step 1: Confirm True Hematuria

• Verify microscopic hematuria with ≥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, as dipstick tests have only 65-99% specificity and produce false positives. 1
• For gross hematuria, confirm visible blood and exclude pseudohematuria from foods, medications, or menstrual contamination. 1
• Do not defer evaluation based on anticoagulation or antiplatelet therapy—these medications may unmask underlying pathology but do not cause hematuria themselves. 1, 2

Step 2: Exclude Transient Causes (Only for Microscopic Hematuria)

• If urinary tract infection is suspected (dysuria, urgency, frequency), obtain urine culture before antibiotics, treat the infection, then repeat urinalysis after treatment to document resolution. 1
• If recent vigorous exercise or viral illness occurred, repeat urinalysis after the cause resolves. 1
• Gross hematuria should never be attributed to transient causes and requires immediate evaluation. 1

Step 3: Distinguish Glomerular from Non-Glomerular Sources

• Examine urinary sediment for dysmorphic RBCs (>80% suggests glomerular), red blood cell casts (pathognomonic for glomerular disease), and significant proteinuria (protein-to-creatinine ratio >0.2). 1
• Tea-colored or cola-colored urine suggests glomerular disease; bright red blood suggests lower urinary tract bleeding. 1
• Check serum creatinine, BUN, and complete metabolic panel to assess renal function. 1
• If glomerular features are present, refer to nephrology in addition to completing urologic evaluation—malignancy can coexist with glomerular disease. 1

Step 4: Complete Urologic Evaluation (Mandatory for All Elderly Patients)

Upper Tract Imaging

• Multiphasic CT urography (without and with intravenous contrast) is the imaging procedure of choice, including unenhanced phase, nephrographic phase, and excretory phase to evaluate renal parenchyma and urothelium. 3, 1
• CT urography has the highest sensitivity and specificity for detecting renal cell carcinoma, transitional cell carcinoma, and urolithiasis. 3, 1
• If CT is contraindicated (renal insufficiency, contrast allergy), use MR urography or renal ultrasound with retrograde pyelography as less optimal alternatives. 1
• Renal ultrasound alone is insufficient for comprehensive upper tract evaluation. 1

Lower Tract Evaluation

• Cystoscopy is mandatory for all elderly patients with hematuria to visualize bladder mucosa, urethra, and ureteral orifices for transitional cell carcinoma. 3, 1
• Flexible cystoscopy is preferred over rigid cystoscopy—it causes less pain with equivalent or superior diagnostic accuracy. 1
• Perform cystoscopy even if upper tract imaging is negative, as bladder cancer is the most frequently diagnosed malignancy in hematuria cases. 1

Additional Testing

• Voided urine cytology should be obtained in high-risk elderly patients to detect high-grade urothelial carcinomas and carcinoma in situ. 1
• Complete blood count with platelets to evaluate for coagulopathy. 1

Step 5: Risk Stratification for Elderly Patients

All elderly patients (≥60 years) are automatically high-risk and require full evaluation. 1 Additional high-risk features include:

• Smoking history >30 pack-years (highest risk for urothelial carcinoma). 1
• Any history of gross hematuria (even if currently microscopic). 1
• Occupational exposure to benzenes, aromatic amines, or chemical dyes. 3, 1
• Irritative voiding symptoms (urgency, frequency, nocturia) without infection. 3, 1
• >25 RBCs/HPF on microscopic examination. 1, 2

Step 6: Follow-Up Protocol if Initial Workup is Negative

• Repeat urinalysis, voided urine cytology, and blood pressure measurement at 6,12,24, and 36 months. 1
• Immediate re-evaluation is warranted if:
  • Recurrent gross hematuria develops. 1
  • Significant increase in degree of microscopic hematuria occurs. 1
  • New urologic symptoms appear (flank pain, irritative voiding). 1
  • Development of hypertension, proteinuria, or evidence of glomerular bleeding. 1
• After two consecutive negative annual urinalyses, no further testing for asymptomatic microhematuria is necessary. 1
• Hematuria can precede bladder cancer diagnosis by many years, making long-term surveillance essential in high-risk elderly patients. 1

Critical Pitfalls to Avoid

• Never ignore gross hematuria, even if self-limited—it carries a 30-40% malignancy risk and mandates urgent urologic referral. 1, 4
• Never attribute hematuria to benign prostatic hyperplasia (BPH) without complete evaluation—BPH can cause hematuria but does not exclude concurrent malignancy. 1, 2
• Never defer evaluation due to anticoagulation therapy—these medications unmask underlying pathology requiring investigation. 1, 2
• Do not prescribe antibiotics for persistent hematuria without documented infection—this delays cancer diagnosis and provides false reassurance. 1
• Delays in diagnosis beyond 9 months from first hematuria presentation are associated with worse cancer-specific survival in bladder cancer patients. 1

Special Considerations for Elderly Patients

• Males ≥60 years are classified as high-risk and require cystoscopy and CT urography regardless of other factors. 1
• Females ≥60 years are systematically under-evaluated compared to men (8-28% vs 36-47% referral rates), yet present with more advanced bladder cancer and higher mortality rates—this disparity must be corrected. 4
• Elderly patients in long-term care facilities with gross hematuria usually have underlying genitourinary abnormalities when investigated, and afebrile hematuria without irritative symptoms probably does not require antimicrobial therapy. 5