What is the appropriate management for a male patient whose urinalysis shows 4‑7 red blood cells per high‑power field, 10‑12 white blood cells per high‑power field, and +5 proteinuria?

Management of Urinalysis Showing RBC 4-7/HPF, WBC 10-12/HPF, and Protein +5

Immediate Priority: Treat the Urinary Tract Infection First

This patient requires immediate antibiotic therapy for a urinary tract infection, followed by repeat urinalysis 6 weeks after treatment to determine if hematuria and proteinuria persist. 1

The combination of 10-12 WBC/HPF with 4-7 RBC/HPF strongly suggests an active urinary tract infection that must be treated before any further urologic evaluation. 1 The presence of pyuria (elevated WBCs) does not exclude underlying pathology, but infection is the most likely explanation for this constellation of findings and should be addressed first. 1

---

Step 1: Antibiotic Treatment

• Initiate empiric antibiotic therapy based on local resistance patterns—typical first-line agents include ciprofloxacin 500 mg every 12 hours for 7-14 days, trimethoprim-sulfamethoxazole, or nitrofurantoin, depending on local susceptibility data. 1, 2

• Obtain urine culture before starting antibiotics if possible, to guide therapy if the patient fails to respond or if resistant organisms are suspected. 1

• Complete the full antibiotic course (typically 7-14 days for uncomplicated UTI in males). 2

---

Step 2: Repeat Urinalysis 6 Weeks After Treatment

• Perform repeat urinalysis with microscopy 6 weeks after completing antibiotics to assess whether hematuria and proteinuria have resolved. 1, 3

• If hematuria and proteinuria resolve completely, no further urologic evaluation is necessary at this time. 1

• If hematuria persists (≥3 RBC/HPF) after infection treatment, proceed with complete urologic evaluation as outlined below. 1

---

Step 3: If Hematuria Persists—Determine Glomerular vs. Non-Glomerular Source

Examine the Urinary Sediment

• Look for dysmorphic RBCs (>80% suggests glomerular origin) and red cell casts (pathognomonic for glomerular disease). 4, 3

• Quantify proteinuria using a spot urine protein-to-creatinine ratio—values >0.5 g/g strongly suggest renal parenchymal (glomerular) disease. 4, 3

• Measure serum creatinine to assess renal function; elevated creatinine suggests glomerular pathology. 4, 3

If Glomerular Features Are Present:

• Refer urgently to nephrology if any of the following are present: 4, 3

  • Proteinuria >500 mg/24 hours (or protein-to-creatinine ratio >0.5 g/g)
  • Red cell casts or >80% dysmorphic RBCs
  • Elevated serum creatinine or declining renal function
  • Hypertension with hematuria and proteinuria

• Nephrology workup will include complement levels (C3, C4), ANA, ANCA if vasculitis is suspected, and consideration of renal biopsy for definitive diagnosis. 4

If Non-Glomerular (Urologic) Features Are Present:

• Proceed with complete urologic evaluation as outlined below. 4, 3

---

Step 4: Complete Urologic Evaluation (If Hematuria Persists After Infection Treatment)

Upper Tract Imaging

• Multiphasic CT urography is the preferred imaging modality (unenhanced, nephrographic, and excretory phases) to detect renal cell carcinoma, transitional cell carcinoma, and urolithiasis. 4, 1

• Alternative imaging (MR urography or renal ultrasound with retrograde pyelography) may be used if CT is contraindicated due to renal insufficiency or contrast allergy, though these are less optimal. 4

Lower Tract Evaluation

• Flexible cystoscopy is mandatory to visualize the bladder mucosa, urethra, and ureteral orifices and to exclude bladder cancer. 4, 1

• Flexible cystoscopy is preferred over rigid cystoscopy because it causes less pain and has equivalent or superior diagnostic accuracy. 4

Additional Testing

• Voided urine cytology should be obtained in high-risk patients (age >40 years, smoking history, occupational exposure to chemicals/dyes, history of gross hematuria) to detect high-grade urothelial carcinomas and carcinoma in situ. 4, 1

---

Step 5: Follow-Up Protocol If Initial Workup Is Negative

• Repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring at each visit. 4, 3

• Immediate re-evaluation is warranted if: 4, 3

  • Gross hematuria develops
  • Significant increase in degree of microscopic hematuria
  • New urologic symptoms appear (flank pain, dysuria, irritative voiding symptoms)
  • Development of hypertension, proteinuria, or evidence of glomerular bleeding

• After two consecutive negative annual urinalyses, no further testing for asymptomatic microhematuria is necessary. 4

---

Critical Pitfalls to Avoid

• Never ignore persistent hematuria after infection treatment—even if the initial UTI explains the WBCs, hematuria that persists after antibiotic therapy requires full urologic evaluation because infection does not cause hematuria; it may only unmask underlying pathology. 4, 1

• Do not prescribe additional courses of antibiotics for persistent hematuria—this delays cancer diagnosis and provides false reassurance. 4

• Do not defer evaluation based on the presence of infection—treat the infection first, but if hematuria persists, proceed with complete urologic workup. 4, 1

• The +5 proteinuria is unusually high and may indicate glomerular disease; if proteinuria persists after infection treatment, nephrology referral is mandatory. 3, 5

---

Summary Algorithm

1. Treat UTI with appropriate antibiotics for 7-14 days. 1, 2
2. Repeat urinalysis 6 weeks after treatment. 1, 3
3. If hematuria resolves, no further workup needed. 1
4. If hematuria persists, examine sediment for dysmorphic RBCs, quantify proteinuria, and measure serum creatinine. 4, 3
5. If glomerular features present, refer to nephrology. 4, 3
6. If non-glomerular features present, proceed with CT urography and cystoscopy. 4, 1
7. If initial workup negative, repeat urinalysis at 6,12,24, and 36 months. 4, 3