How should I evaluate and manage a patient presenting with blood‑stained urine along with dysuria, frequency, and urgency suggestive of cystitis?

Management of Blood-Stained Urine in Cystitis

Immediate Diagnostic Approach

In a patient presenting with dysuria, frequency, urgency, and hematuria suggestive of cystitis, you should first confirm true urinary tract infection with urinalysis and urine culture, then treat the infection and reassess hematuria after treatment completion. 1

Confirm the Clinical Diagnosis

• Obtain urinalysis looking specifically for pyuria (white blood cells), which is typically present with UTI regardless of location—its absence suggests another condition may be causing symptoms 2
• Collect urine culture before starting antibiotics to document infection and guide therapy if symptoms persist 1, 3
• Perform microscopic urinalysis to confirm true hematuria (≥3 RBCs per high-power field) rather than relying on dipstick alone, which has only 65-99% specificity 4
• Examine for dysuria, frequency, and urgency as the classic triad—these symptoms in an immunocompetent woman of childbearing age with no comorbidities strongly suggest uncomplicated cystitis 3

Risk Stratification: Uncomplicated vs. Complicated

Determine whether this is uncomplicated cystitis (simple bladder infection in a healthy woman) or complicated UTI, as this fundamentally changes your management approach. 5

• Uncomplicated cystitis presents with frequency, urgency, and dysuria in an immunocompetent woman with no anatomic abnormalities, no fever, and no flank pain 1, 3
• Complicated UTI is defined by male sex, pregnancy, diabetes, immunosuppression, catheterization, anatomical abnormalities, or systemic symptoms (fever ≥37.8°C, flank pain, nausea/vomiting) 5
• Physical examination should be normal or show only suprapubic tenderness in uncomplicated cystitis; costovertebral angle tenderness suggests pyelonephritis 3, 2

Treatment of the Infection

First-Line Antibiotic Therapy for Uncomplicated Cystitis

Choose one of three guideline-recommended first-line agents: 1, 3

• Nitrofurantoin (preferred in most settings)

• Fosfomycin (single-dose option)

• Trimethoprim-sulfamethoxazole (only if local E. coli resistance is <20%)

• Avoid beta-lactams (amoxicillin/clavulanate, cefaclor, cefdinir, cefpodoxime) as initial therapy due to resistance concerns 3

• Treatment duration is typically 3-7 days for uncomplicated cystitis 1

When to Obtain Urine Culture

Urine culture is mandatory in the following situations: 1, 3

• Suspected pyelonephritis (fever, flank pain, systemic symptoms)
• Symptoms that do not resolve or recur within 2-4 weeks after treatment
• Atypical symptoms or complicated UTI
• Pregnant women
• All complicated UTIs require culture with antimicrobial susceptibility testing before initiating therapy 5

Post-Treatment Hematuria Assessment

The Critical Decision Point

After completing antibiotic therapy, repeat urinalysis 6 weeks post-treatment to determine if hematuria has resolved. 4

• If hematuria resolves after treating the infection in a low-risk patient, no further urologic workup is needed 4
• If hematuria persists after infection treatment, proceed immediately with full urologic evaluation regardless of age or risk factors 4

Full Urologic Evaluation for Persistent Hematuria

Persistent hematuria after treating UTI requires comprehensive assessment because infection does not exclude concurrent malignancy. 4

Risk Stratification for Malignancy

High-risk features that mandate complete evaluation include: 4

• Age ≥60 years (men or women)
• Smoking history >30 pack-years
• Occupational exposure to chemicals/dyes (benzenes, aromatic amines)
• History of gross hematuria
• Irritative voiding symptoms without documented infection
• Degree of hematuria >25 RBCs/HPF

Required Diagnostic Studies

• Multiphasic CT urography (unenhanced, nephrographic, and excretory phases) is the preferred imaging modality to detect renal cell carcinoma, transitional cell carcinoma, and urolithiasis 4
• Flexible cystoscopy is mandatory for all patients ≥40 years or those with high-risk features to visualize bladder mucosa and exclude transitional cell carcinoma 4
• Urine cytology should be obtained in high-risk patients (age >60, smoking >30 pack-years, occupational exposures) 4

Special Considerations and Pitfalls

Common Diagnostic Errors to Avoid

• Never attribute persistent hematuria solely to UTI without confirming resolution after treatment—pyuria does not differentiate infection from malignancy 4, 5
• Do not delay urologic evaluation in patients with gross hematuria, which carries a 30-40% malignancy risk even when infection is present 4
• Anticoagulation or antiplatelet therapy does not cause hematuria—these medications may unmask underlying pathology but evaluation must proceed regardless 4
• Cloudy urine, odor, or color change alone should not be relied upon to diagnose UTI, as these can occur with asymptomatic bacteriuria 5

When Hematuria Suggests Non-Infectious Etiology

Consider alternative diagnoses if: 4

• Tea-colored or cola-colored urine (suggests glomerular disease)
• Significant proteinuria (protein-to-creatinine ratio >0.5 g/g)

• 80% dysmorphic RBCs or red cell casts on microscopy (indicates glomerular bleeding—requires nephrology referral in addition to urologic evaluation)

• Absence of pyuria despite urinary symptoms

Interstitial Cystitis Consideration

Hematuria occurs in up to 30-41% of patients with interstitial cystitis, which presents with frequency, urgency, and suprapubic/pelvic pain but has negative urine cultures and no response to antibiotics 6, 7

• Interstitial cystitis should be considered when symptoms persist despite negative cultures and failed antibiotic trials 7
• However, complete urologic evaluation is still required to exclude malignancy, as hematuria evaluation in IC patients rarely reveals life-threatening conditions but cannot be omitted 6

Algorithmic Summary

1. Confirm UTI: Urinalysis + urine culture (before antibiotics)
2. Treat infection: First-line agent for 3-7 days
3. Reassess at 6 weeks: Repeat urinalysis
4. If hematuria resolved: No further workup needed
5. If hematuria persists: Full urologic evaluation (CT urography + cystoscopy)
6. If high-risk features present: Proceed directly to full evaluation even if infection treated