What are the recommendations for a patient with a painless, hypermobile mass in the left inguinal area for over a year, accompanied by a history of microscopic hematuria?

Urgent Urologic Evaluation Required for High-Risk Hematuria

This patient requires immediate urologic referral for complete evaluation with cystoscopy and CT urography, regardless of the inguinal mass findings. The combination of microscopic hematuria persisting over a year in a patient with an unexplained inguinal mass represents high-risk features that mandate comprehensive urologic assessment to exclude malignancy 1, 2.

Immediate Diagnostic Priorities

Confirm True Microscopic Hematuria

• Verify microscopic hematuria with ≥3 red blood cells per high-power field on microscopic examination of properly collected urine specimens 1, 2
• Do not rely solely on dipstick testing, which has only 65-99% specificity and can produce false positives 1, 3
• For high-risk patients, even a single urinalysis with ≥3 RBC/HPF may warrant full evaluation 2

Complete Urologic Evaluation Components

• Multiphasic CT urography is the preferred imaging modality to detect renal cell carcinoma, transitional cell carcinoma, and urolithiasis 1, 2, 4
• Flexible cystoscopy is mandatory to evaluate the bladder for transitional cell carcinoma, which is the most frequently diagnosed malignancy in hematuria cases 1, 2
• Serum creatinine measurement to assess renal function 1, 2
• Complete urinalysis with microscopy to examine for dysmorphic RBCs (>80% suggests glomerular origin) and red cell casts 1, 3

Evaluation of the Inguinal Mass

The inguinal mass requires separate surgical evaluation and should not delay hematuria workup. A painless, hypermobile, dime-sized mass in the inguinal region for over a year could represent:

• Inguinal lymphadenopathy (concerning for metastatic disease given the hematuria) 1
• Inguinal hernia 1
• Lipoma or other benign soft tissue mass 1

Critical Integration Point

• The presence of both an inguinal mass and microscopic hematuria raises concern for metastatic urologic malignancy, particularly bladder or upper tract urothelial carcinoma with lymph node involvement 1, 2
• Physical examination should include palpation of the mass, assessment for reducibility, and evaluation for other lymphadenopathy 1
• If the mass represents lymphadenopathy, this would significantly alter staging and prognosis if urologic malignancy is discovered 1

Risk Stratification for Malignancy

This patient has multiple high-risk features that elevate concern for urologic malignancy:

• Duration of hematuria >1 year indicates persistent pathology requiring investigation 1, 2
• Presence of unexplained inguinal mass raises concern for lymphatic spread 1
• Microscopic hematuria carries 2.6-4% overall malignancy risk, but this increases substantially with additional risk factors 1, 2

Additional Risk Factors to Assess

• Age (males ≥60 years or females ≥60 years are high-risk) 1, 2
• Smoking history (>30 pack-years is high-risk) 1, 2
• Occupational exposure to chemicals/dyes (benzenes, aromatic amines) 1, 2, 3
• History of gross hematuria 1, 2
• Irritative voiding symptoms (urgency, frequency, nocturia) 1, 2

Exclude Glomerular Disease

Before proceeding with urologic evaluation, assess for signs of renal parenchymal disease:

• Examine urinary sediment for dysmorphic RBCs (>80% suggests glomerular origin) and red cell casts (pathognomonic for glomerular disease) 1, 2, 3
• Check for significant proteinuria using spot urine protein-to-creatinine ratio (>0.5 g/g suggests renal parenchymal disease) 1, 2
• Measure serum creatinine to identify renal insufficiency 1, 2
• If glomerular features are present, pursue both nephrology AND urology referrals concurrently, as malignancy can coexist with medical renal disease 1, 2

Critical Pitfalls to Avoid

• Never attribute persistent hematuria to benign causes without complete evaluation - even if a benign explanation is identified, the duration and presence of the inguinal mass mandate full workup 1, 2
• Do not delay evaluation for anticoagulation or antiplatelet therapy - these medications may unmask underlying pathology but do not cause hematuria 1, 3
• Do not assume the inguinal mass is unrelated - it could represent metastatic disease and must be evaluated concurrently 1
• Hematuria persisting >1 year without evaluation represents a significant delay - delays beyond 9 months from first hematuria presentation are associated with worse cancer-specific survival in bladder cancer patients 1

Immediate Management Algorithm

1. Confirm microscopic hematuria with microscopic urinalysis showing ≥3 RBCs/HPF 1, 2
2. Assess for glomerular disease with urinary sediment examination, proteinuria assessment, and serum creatinine 1, 2
3. Urgent urology referral for cystoscopy and multiphasic CT urography 1, 2
4. Concurrent surgical evaluation of the inguinal mass with physical examination and consideration of ultrasound or CT imaging 1
5. If CT urography shows lymphadenopathy corresponding to the palpable inguinal mass, this suggests advanced disease requiring oncologic staging 1

Follow-Up Considerations

• If initial workup is negative but hematuria persists, repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring 1, 3
• Consider repeat complete evaluation within 3-5 years for persistent hematuria in high-risk patients 1, 2
• Immediate re-evaluation is warranted if gross hematuria develops, significant increase in microscopic hematuria occurs, or new urologic symptoms appear 1, 2

The year-long delay in evaluation is concerning and should be addressed immediately. Early detection of urologic malignancy significantly impacts mortality and morbidity, and evaluation should not be delayed further 2.