From the Guidelines
The workup for gross hematuria should begin with a thorough history and physical examination, followed by urinalysis with microscopy to confirm the presence of red blood cells, and initial laboratory tests should include complete blood count, basic metabolic panel, and coagulation studies, as recommended by the American College of Radiology 1. Imaging studies typically start with a CT urogram, which can detect urinary tract stones, tumors, and other structural abnormalities. Cystoscopy is recommended for all adults with gross hematuria to directly visualize the bladder and urethra, particularly to evaluate for bladder cancer, as suggested by the American College of Physicians 1. For patients over 35 years old or those with risk factors like smoking or chemical exposures, upper tract imaging is crucial even if initial tests are negative. Additional specialized tests may include urine cytology to detect malignant cells, and in some cases, renal biopsy if glomerular disease is suspected. This comprehensive approach is necessary because gross hematuria can indicate serious conditions including malignancy, urolithiasis, or glomerulonephritis, and prompt diagnosis is essential for appropriate treatment, as emphasized by the Journal of the American College of Radiology 1. Some key points to consider in the workup of gross hematuria include:
- A thorough history and physical examination to identify potential causes and risk factors
- Urinalysis with microscopy to confirm the presence of red blood cells
- Initial laboratory tests, including complete blood count, basic metabolic panel, and coagulation studies
- Imaging studies, starting with a CT urogram, to detect urinary tract stones, tumors, and other structural abnormalities
- Cystoscopy to directly visualize the bladder and urethra, particularly to evaluate for bladder cancer
- Upper tract imaging for patients over 35 years old or those with risk factors like smoking or chemical exposures
- Additional specialized tests, such as urine cytology or renal biopsy, as needed. Patients should be referred to a urologist if no immediate cause is found or if there are concerning findings on initial evaluation, as recommended by the American College of Physicians 1.
From the Research
Workup for Gross Hematuria
The workup for gross hematuria involves a thorough history and physical examination to determine potential causes and assess risk factors for malignancy 2. The risk of malignancy with gross hematuria is greater than 10%, and prompt urologic referral is recommended 2.
Diagnostic Techniques
Various diagnostic techniques can be used to evaluate gross hematuria, including:
- Plain X-rays of the kidney, ureter, and bladder
- Ultrasound
- Intravenous urography
- Computed Tomography (CT)
- Magnetic Resonance Imaging
- Retrograde ureterography and pyelography (RGP)
- Cystoscopy
- Ureteroscopy 3
CT Urography
CT urography is a useful technique for evaluating gross hematuria, and it can be used alone for this task 3. The protocol for CT urography includes:
- Unenhanced scan to evaluate the size, shape, position, and outline of the kidneys and calculus disease
- Nephrographic phase to visualize renal parenchymal diseases, including masses
- Excretory phase to detect urothelial diseases 3
Individualized Approach
The workup for gross hematuria should be individualized based on the patient's clinical scenario, and it may include laboratory tests, imaging studies, and referral to subspecialists 4, 5. In some cases, a limited workup may be sufficient, especially if the patient has a benign condition such as essential unilateral hematuria 6.