What are the possible causes of acute gross hematuria in a woman presenting with lower abdominal (hypogastric) pain and generalized malaise?

Acute Gross Hematuria with Hypogastric Pain and Malaise in Females

Most Likely Causes in Order of Clinical Priority

In a woman presenting with acute gross hematuria, lower abdominal pain, and systemic malaise, the most urgent differential includes hemorrhagic cystitis (infectious or chemical), complicated urinary tract infection with bladder involvement, urolithiasis with obstruction, and less commonly, bladder malignancy—though the acute presentation with pain and constitutional symptoms makes infection or stone disease more probable than cancer alone. 1, 2

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Primary Urologic/Infectious Causes

Hemorrhagic Cystitis / Complicated UTI

• Urinary tract infection is the most common cause of both microscopic and macroscopic hematuria in women, particularly when accompanied by dysuria, urgency, frequency, suprapubic pain, and systemic symptoms like fever or malaise 1, 2
• The combination of gross hematuria + hypogastric pain + malaise strongly suggests bacterial cystitis with bladder mucosal inflammation and hemorrhage 1, 2
• Obtain urine culture before initiating antibiotics to document the pathogen and guide therapy 1
• Pyuria (white blood cells in urine) and bacteriuria on microscopy confirm infection, though their presence does not exclude concurrent malignancy in high-risk patients 1, 3

Urolithiasis (Bladder or Ureteral Stone)

• Kidney and ureteric stones typically cause painful hematuria with flank pain, but stones lodged at the ureterovesical junction or within the bladder can produce hypogastric pain and gross hematuria 1, 2
• The acute onset with colicky pain radiating to the groin or suprapubic region is characteristic 1
• Multiphasic CT urography is 96% sensitive and 99% specific for detecting urolithiasis and should be performed if infection is excluded or symptoms persist despite treatment 1

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Malignancy (Must Be Excluded Despite Acute Presentation)

Bladder Cancer

• Gross hematuria carries a 30–40% risk of underlying malignancy in adults, making bladder cancer the most frequently diagnosed malignancy in hematuria cases 1, 2, 3
• Painless gross hematuria is the classic presentation, but bladder tumors can become symptomatic with irritative voiding symptoms (urgency, frequency) mimicking UTI 1, 3
• Risk factors include age >35–40 years, smoking history, and occupational exposure to benzenes or aromatic amines 1, 2
• Cystoscopy is mandatory for all women with gross hematuria to directly visualize the bladder mucosa, even if imaging is normal 1, 3

Upper Tract Urothelial Carcinoma

• Transitional cell carcinoma of the renal pelvis or ureter can present with gross hematuria and flank/hypogastric pain if obstruction occurs 1
• CT urography is the preferred imaging modality to detect upper tract malignancies 1, 2

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Renal/Glomerular Causes (Less Likely with Isolated Hypogastric Pain)

Glomerulonephritis

• Tea-colored or cola-colored urine accompanied by proteinuria, red blood cell casts, and dysmorphic RBCs (>80%) strongly suggests glomerular disease 1, 2
• Post-infectious glomerulonephritis (following streptococcal infection) and IgA nephropathy are common glomerular causes 2
• Glomerular bleeding typically does NOT cause hypogastric pain—the pain localizes to the flanks or is absent 1
• If urinalysis shows significant proteinuria (>500 mg/24h), dysmorphic RBCs, or red cell casts, refer to nephrology in addition to completing urologic evaluation 1

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Systemic/Other Causes

Coagulopathy or Anticoagulation

• Coagulopathies (hemophilia) and anticoagulant/antiplatelet medications may unmask underlying pathology but do NOT cause hematuria themselves 1, 2
• Evaluation must proceed regardless of anticoagulation status 1

Menstrual Contamination

• Menstruation can cause false-positive dipstick results in women; obtain a catheterized urine specimen if clean-catch is unreliable 1
• True hematuria requires microscopic confirmation of ≥3 RBCs per high-power field 1, 2

Trauma

• Any history of abdominal or pelvic trauma (including sexual activity or instrumentation) can cause bladder or urethral injury with gross hematuria 1, 2

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Diagnostic Algorithm

Step 1: Confirm True Hematuria

• Perform microscopic urinalysis on a clean-catch midstream specimen and verify ≥3 RBCs/HPF 1, 2
• Dipstick testing alone has only 65–99% specificity and may yield false positives from myoglobin, hemoglobin, or menstrual blood 1

Step 2: Assess for Infection

• Obtain urinalysis with microscopy looking for pyuria, bacteriuria, and white blood cell casts 1, 3
• Send urine culture before starting antibiotics 1
• If infection is confirmed, treat appropriately and repeat urinalysis 6 weeks after treatment—if hematuria persists, proceed with full urologic evaluation 1

Step 3: Distinguish Glomerular vs. Urologic Source

• Glomerular indicators: Tea-colored urine, proteinuria >500 mg/24h, dysmorphic RBCs >80%, red cell casts 1, 2
• Urologic indicators: Normal-shaped RBCs >80%, minimal proteinuria, acute onset with pain 1, 2

Step 4: Risk Stratification for Malignancy

• High-risk features (require urgent cystoscopy + CT urography): Age >35–40 years, smoking >30 pack-years, occupational chemical exposure, irritative voiding symptoms without infection, any gross hematuria 1, 2, 3
• All women with gross hematuria require urgent urologic referral regardless of other factors 1, 3

Step 5: Imaging and Endoscopy

• Multiphasic CT urography (unenhanced, nephrographic, excretory phases) is the preferred imaging modality for detecting malignancy, stones, and anatomic abnormalities 1, 2
• Flexible cystoscopy is mandatory for all patients with gross hematuria to visualize bladder mucosa and exclude transitional cell carcinoma 1, 3
• Renal ultrasound alone is insufficient for comprehensive evaluation 1

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Critical Pitfalls to Avoid

• Never ignore gross hematuria, even if self-limited—30–40% malignancy risk mandates urgent evaluation 1, 2, 3
• Do not attribute hematuria solely to UTI without follow-up—if hematuria persists after treating infection, complete urologic workup is required 1
• Do not defer evaluation due to anticoagulation—these medications unmask pathology but do not cause hematuria 1, 2
• Do not rely on dipstick alone—confirm with microscopic urinalysis showing ≥3 RBCs/HPF 1, 2
• Infection does not exclude malignancy—pyuria and bacteriuria can coexist with bladder cancer 1, 3

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Immediate Management

• If fever, rigors, or sepsis signs are present, initiate empiric antibiotics immediately (fluoroquinolone or ceftriaxone for suspected pyelonephritis) 1
• If hemodynamically unstable, assess for significant blood loss with hemoglobin/hematocrit monitoring and consider resuscitation 4, 3
• Refer urgently to urology (within 24–48 hours) for cystoscopy and imaging if gross hematuria is confirmed 1, 3