What is the best course of action for an elderly patient presenting with hematuria, found to have probable bilateral renal cysts, colonic diverticulosis, a left fat-containing inguinal hernia, and a subpleural nodule in the right lung base on CT scan?

Immediate Management of Hematuria with Incidental CT Findings in an Elderly Patient

This elderly patient requires urgent urologic referral for cystoscopy and comprehensive hematuria evaluation, regardless of the CT findings showing probable renal cysts and other incidental findings. The hematuria itself—not the CT results—drives the management algorithm.

Primary Issue: Hematuria Evaluation Takes Priority

• Gross or microscopic hematuria in an elderly patient carries a 30-40% risk of malignancy and mandates complete urologic evaluation with cystoscopy and upper tract imaging, even when initial CT shows benign-appearing findings 1, 2.
• The CT scan you ordered was non-contrast, which is inadequate for comprehensive hematuria evaluation—the preferred imaging is multiphasic CT urography (with contrast phases) to detect urothelial carcinomas, renal cell carcinomas, and other pathology 1, 2.
• Age >60 years alone classifies this patient as high-risk for urologic malignancy, requiring full evaluation regardless of other factors 1, 3.

Addressing the CT Findings Systematically

1. Probable Bilateral Renal Cysts

• Simple renal cysts are extremely common in elderly patients and do not explain hematuria 4, 5.
• The radiologist's recommendation to "correlate with ultrasound if warranted" is not the next step—this patient needs urologic evaluation for the hematuria first 1, 2.
• Hemorrhagic renal cysts can cause hematuria but require contrast-enhanced CT or MRI to distinguish from malignancy—your non-contrast CT cannot make this determination 4.
• If cysts are truly simple (which requires contrast imaging to confirm), they need no further workup; if complex or hemorrhagic, they require serial imaging after malignancy is excluded 4.

2. Subpleural Lung Nodule (3 x 7 mm)

• This incidental finding requires separate management per lung nodule guidelines, but does not change the urgency of hematuria evaluation 1.
• A 3-7 mm nodule in an elderly patient typically warrants follow-up CT chest in 12 months if low-risk, or 6-12 months if high-risk features present (smoking history, etc.).
• Address this separately after completing hematuria workup—do not let this distract from the primary issue.

3. Colonic Diverticulosis and Left Inguinal Hernia

• Diverticulosis does not cause hematuria 1, 5.
• The fat-containing left inguinal hernia is likely asymptomatic and incidental 6.
• While rare case reports describe inguinal hernias causing hematuria through bladder compression, your CT shows no evidence of bladder compression, hydronephrosis, or ureteral obstruction 6.
• These findings require no immediate action related to the hematuria evaluation.

Required Immediate Actions

Step 1: Confirm True Hematuria

• Obtain formal microscopic urinalysis showing ≥3 RBCs per high-power field on a properly collected clean-catch midstream specimen 1, 2.
• If you relied on dipstick alone, this must be confirmed microscopically (dipstick has only 65-99% specificity) 1, 2.
• Examine urinary sediment for dysmorphic RBCs (>80% suggests glomerular source) and red cell casts (pathognomonic for glomerular disease) 1, 2.

Step 2: Rule Out Benign Transient Causes

• Obtain urine culture to exclude urinary tract infection—if positive, treat appropriately and repeat urinalysis 6 weeks after treatment completion 1, 2.
• If hematuria resolves after treating infection, no further urologic evaluation needed 1.
• If hematuria persists after treating infection, proceed with full urologic evaluation 1.
• Assess for recent vigorous exercise, sexual activity, or trauma—if present and hematuria resolves 48 hours after cessation, no further workup needed 1.

Step 3: Assess for Glomerular Disease

• Check serum creatinine, BUN, and spot urine protein-to-creatinine ratio 1, 2.
• Significant proteinuria (>500 mg/24 hours or protein-to-creatinine ratio >0.5), dysmorphic RBCs >80%, red cell casts, or elevated creatinine warrant nephrology referral in addition to completing urologic evaluation 1, 2.
• The presence of glomerular features does not eliminate the need for urologic evaluation—malignancy can coexist with medical renal disease 1, 2.

Step 4: Complete Urologic Evaluation

• Urgent urology referral for cystoscopy—this is mandatory for all elderly patients with hematuria to visualize bladder mucosa, urethra, and ureteral orifices 1, 2, 3.
• Order multiphasic CT urography (with contrast) if renal function permits—your non-contrast CT is insufficient for comprehensive upper tract evaluation 1, 2.
• If contrast is contraindicated due to renal insufficiency, consider MR urography or renal ultrasound with retrograde pyelography 1, 2.
• Flexible cystoscopy is preferred over rigid cystoscopy (less pain, equivalent diagnostic accuracy) 1, 2.

Critical Pitfalls to Avoid

• Never attribute hematuria to "probable renal cysts" without tissue diagnosis—this delays cancer detection and worsens outcomes 1, 2.
• Never defer evaluation because the patient is on anticoagulation or antiplatelet therapy—these medications may unmask underlying pathology but do not cause hematuria 1, 2.
• Never assume a benign cause without completing full evaluation in an elderly patient—delays beyond 9 months are associated with worse cancer-specific survival 1, 2.
• Do not order ultrasound as the next step—this patient needs cystoscopy and contrast-enhanced imaging, not ultrasound correlation of cysts 1, 2.

Follow-Up Protocol if Initial Evaluation is Negative

• If complete workup (cystoscopy + CT urography) is negative but hematuria persists, repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring at each visit 7, 1.
• Immediate re-evaluation is warranted if gross hematuria develops, significant increase in microscopic hematuria occurs, or new urologic symptoms appear 1, 2.
• Consider repeat complete evaluation within 3-5 years for persistent hematuria in high-risk patients 1.

Summary Algorithm

1. Confirm microscopic hematuria (≥3 RBCs/HPF) and exclude contamination 1, 2
2. Rule out UTI with urine culture; if positive, treat and recheck in 6 weeks 1
3. Assess for glomerular disease (proteinuria, dysmorphic RBCs, creatinine) 1, 2
4. Urgent urology referral for cystoscopy (mandatory for all elderly patients) 1, 2, 3
5. Order multiphasic CT urography (your non-contrast CT is inadequate) 1, 2
6. Nephrology referral if glomerular features present (but still complete urologic workup) 1, 2
7. Address lung nodule and other incidental findings separately after completing hematuria evaluation