Tea-Colored Urine Workup
Tea-colored or cola-colored urine strongly suggests glomerular disease and requires immediate urinalysis with microscopy to differentiate true hematuria from hemoglobinuria, myoglobinuria, or pigmenturia, followed by risk-stratified evaluation for both glomerular and urologic causes. 1, 2
Immediate Diagnostic Steps
- Obtain urinalysis with microscopy immediately to confirm true hematuria (≥3 RBCs per high-power field) versus hemoglobinuria, myoglobinuria, or pigmenturia from medications/foods 1, 2, 3
- Dipstick testing alone has only 65-99% specificity and produces false positives—microscopic confirmation is mandatory before proceeding with extensive workup 1, 4
- Tea-colored urine specifically suggests glomerular bleeding, while bright red urine indicates lower urinary tract sources 1
Essential Laboratory Evaluation
- Complete urinalysis with microscopy examining for dysmorphic RBCs (>80% dysmorphic suggests glomerular source), red cell casts (pathognomonic for glomerular disease), proteinuria, and other cellular elements 1, 5
- Urine culture (preferably before antibiotics) to exclude urinary tract infection, even if infection seems unlikely 1, 2
- Serum creatinine, BUN, and complete metabolic panel to assess renal function and identify medical renal disease 1, 2, 4
- Spot urine protein-to-creatinine ratio if proteinuria is present on dipstick (normal <0.2 g/g)—significant proteinuria accompanying hematuria strongly suggests glomerular disease 1
Risk Stratification for Urologic Malignancy
Even with suspected glomerular disease, assess for high-risk features requiring complete urologic evaluation:
- Age ≥60 years in men or women 2
- Smoking history >30 pack-years 1, 2
- Occupational exposure to chemicals, dyes, benzenes, or aromatic amines 6, 2
- Irritative voiding symptoms without infection 1, 2
- History of gross hematuria (even if self-limited, carries 30-40% malignancy risk) 1, 2
- History of pelvic irradiation or cyclophosphamide exposure 6, 2
Complete Urologic Evaluation (If High-Risk Features Present)
- Multiphasic CT urography (without and with IV contrast) is the imaging modality of choice for detecting renal cell carcinoma, transitional cell carcinoma, and urolithiasis—includes sufficient phases to evaluate renal parenchyma and excretory phase for upper tract urothelium 6, 1, 2, 4
- Cystoscopy is mandatory for all patients with gross hematuria and high-risk microscopic hematuria to visualize bladder mucosa, urethra, and ureteral orifices 6, 1, 2
- Voided urine cytology in high-risk patients to detect high-grade urothelial carcinomas and carcinoma in situ 1, 2
Glomerular Disease Indicators
- >80% dysmorphic RBCs on phase-contrast microscopy suggests glomerular source 1
- Red blood cell casts are pathognomonic for glomerular disease 1
- Significant proteinuria (protein-to-creatinine ratio >0.2 g/g) accompanying hematuria suggests glomerular disease 1
- If glomerular disease is suspected, nephrology referral is indicated for further evaluation including possible renal biopsy 7
Critical Pitfalls to Avoid
- Never dismiss hematuria in patients on anticoagulation or antiplatelet therapy—these medications unmask underlying pathology but do not cause hematuria themselves and should not defer evaluation 1, 2, 4
- Never accept self-limited gross hematuria as benign—30-40% harbor malignancy and require complete evaluation 1, 2
- Never confuse hemoglobinuria with hematuria—hemoglobinuria shows positive dipstick for blood but no RBCs on microscopy, and requires evaluation for hemolytic conditions like paroxysmal nocturnal hemoglobinuria 3
- Never attribute tea-colored urine solely to concentrated urine—this color specifically suggests glomerular bleeding or hemoglobinuria and requires full workup 1