For an elderly patient with hematuria, should I start with an X-ray of the kidneys, ureters, and bladder (XR KUB) or an abdominal computed tomography (Abd CT) scan before consulting urology?

Imaging for Elderly Patient with Hematuria Before Urology Referral

For an elderly patient with hematuria, you should order CT urography (multiphase CT with unenhanced, nephrographic, and excretory phases) rather than a plain KUB radiograph, as CT urography is the preferred imaging modality with 96% sensitivity and 99% specificity for detecting urologic pathology. 1, 2

Why CT Urography is Superior to Plain Radiography

Diagnostic Accuracy

• CT urography provides comprehensive evaluation of the entire urinary tract in a single examination, eliminating the need for multiple imaging studies 1, 3
• The American College of Radiology identifies multiphase CT urography as the preferred study for hematuria evaluation, with 99.6% accuracy for kidney and ureter lesions and 98.8% specificity for bladder lesions 1, 2
• Plain KUB radiography has only 59% sensitivity for stone detection and provides no information about soft tissue pathology, obstruction, or urothelial lesions 1, 4

Why Plain KUB is Inadequate

• KUB radiographs miss the majority of clinically significant pathology including renal masses, urothelial carcinomas, and non-calcified stones 4
• Plain films cannot evaluate renal parenchyma, bladder lesions, or urothelial abnormalities that are critical in elderly patients at higher risk for malignancy 2, 4

Required CT Urography Protocol

Three Essential Phases

• Unenhanced phase: Detects all stone compositions and evaluates baseline kidney characteristics 2, 4, 3
• Nephrographic phase (post-contrast): Characterizes renal masses and evaluates parenchymal abnormalities 2, 4, 5
• Excretory phase (≥5 minutes post-contrast): Visualizes urothelium and detects filling defects or urothelial lesions 2, 4, 3

Technical Requirements

• Thin-slice acquisition with multiplanar reconstructions is mandatory for optimal diagnostic yield 2, 4
• Do not accept a standard "CT abdomen/pelvis with contrast" as this lacks the pre-contrast and excretory phases necessary for comprehensive urinary tract evaluation 2

Age and Risk Factor Considerations

Why This Matters in Elderly Patients

• The American Urological Association recommends CT urography for all patients older than 35 years with hematuria 1
• Elderly patients have significantly higher risk for urologic malignancies, making comprehensive imaging essential rather than optional 1
• Age >50 years is specifically identified as a high-risk factor requiring complete imaging evaluation 2

Common Pitfalls to Avoid

Do Not Order These Instead

• Ultrasound is not appropriate as first-line imaging in elderly patients with hematuria, as it detects only 75% of urinary stones and 38% of ureteral stones, with poor sensitivity for urothelial lesions 2, 4
• Intravenous urography (IVU) is obsolete and has been replaced by CT urography 1, 4
• Ordering only a KUB will delay diagnosis and require additional imaging, ultimately exposing the patient to more procedures and delaying urology referral 4

Special Circumstances

Renal Insufficiency

• If eGFR <45 mL/min and CT urography is contraindicated, MR urography without and with IV contrast is the most appropriate alternative 2

When to Consider Alternative Approaches

• In patients with documented benign causes and no risk factors, imaging may be deferred, but this does not apply to elderly patients who inherently have age as a risk factor 2

Clinical Bottom Line

Order CT urography with the complete three-phase protocol (unenhanced, nephrographic, excretory) before urology referral. This single comprehensive examination will provide all necessary diagnostic information and prevent delays in diagnosis of potentially life-threatening conditions like urothelial carcinoma or renal cell carcinoma. 1, 2, 4, 3