Why does a man have microscopic hematuria on urinalysis when the only finding is a small painless spermatocele of the left epididymis on ultrasound?

Why Would a Man Have Microscopic Hematuria with Only a Spermatocele Found?

A spermatocele does not cause hematuria—these are unrelated findings that require separate evaluation. The microscopic hematuria demands a complete urologic workup regardless of the incidental scrotal finding. 1

The Spermatocele Is Not the Explanation

• Spermatoceles are benign epididymal cysts containing sperm and fluid that do not communicate with the urinary tract. 1
• Scrotal pathology (spermatoceles, varicoceles, hydroceles) does not produce blood in the urine because these structures are anatomically separate from the urinary collecting system. 1
• The ultrasound finding is coincidental and should not distract from evaluating the hematuria through proper urologic channels. 1

What Actually Causes Microscopic Hematuria in Men

The most common etiologies include: 1, 2

• Urologic malignancy (bladder cancer, kidney cancer, prostate cancer)—2.6–4% risk in microscopic hematuria, but higher with risk factors 1, 2
• Benign prostatic hyperplasia (BPH)—very common in men, especially over age 50 1, 2
• Urinary tract infection—should resolve after appropriate antibiotic treatment 1, 2
• Urolithiasis (kidney or bladder stones)—may be asymptomatic 1, 2
• Glomerular disease (IgA nephropathy, thin basement membrane disease)—suggested by dysmorphic RBCs, proteinuria, or elevated creatinine 1, 2
• Vigorous exercise—transient and resolves with rest 1

Risk Stratification Determines Next Steps

Age, smoking history, and degree of hematuria determine the urgency and extent of evaluation: 1, 2

High-Risk Features (Require Full Urologic Workup)

• Age ≥60 years 1
• Smoking history >30 pack-years 1

• 25 RBCs per high-power field 1

• History of gross hematuria 1
• Occupational exposure to benzenes or aromatic amines 1, 2
• Irritative voiding symptoms without infection 1

Intermediate-Risk Features (Shared Decision-Making)

• Men age 40–59 years 1
• Smoking history 10–30 pack-years 1
• 11–25 RBCs per high-power field 1

Low-Risk Features (May Defer Extensive Imaging)

• Men <40 years 1
• Never smoker or <10 pack-years 1
• 3–10 RBCs per high-power field 1

Required Diagnostic Workup

First, confirm true microscopic hematuria: 1, 2

• Obtain microscopic urinalysis showing ≥3 RBCs per high-power field on at least two of three properly collected clean-catch midstream specimens 1, 2
• Dipstick alone has only 65–99% specificity and can yield false positives from myoglobin, hemoglobin, or contaminants 1

Distinguish glomerular from urologic sources: 1, 2

• Examine urinary sediment for dysmorphic RBCs (>80% suggests glomerular) and red cell casts (pathognomonic for glomerular disease) 1, 2
• Check for significant proteinuria (spot protein-to-creatinine ratio >0.5 g/g strongly suggests renal parenchymal disease) 1, 2
• Measure serum creatinine to assess renal function 1, 2

For non-glomerular hematuria in men ≥40 years or with high-risk features: 1, 2

• Multiphasic CT urography (unenhanced, nephrographic, and excretory phases) to detect renal cell carcinoma, transitional cell carcinoma, and urolithiasis 1, 2
• Flexible cystoscopy is mandatory to visualize bladder mucosa, urethra, and ureteral orifices—this cannot be replaced by imaging 1, 2
• Urine culture if infection is suspected 1, 2

Common Pitfalls to Avoid

• Do not attribute hematuria to the spermatocele—these are anatomically unrelated structures 1
• Do not defer evaluation if the patient is on anticoagulation or antiplatelet therapy—these medications may unmask underlying pathology but do not cause hematuria 1, 2
• Do not assume a benign cause without proper confirmation—even young men with significant hematuria (>25 RBCs/HPF) can harbor malignancy 3
• Do not skip cystoscopy if imaging is normal—bladder cancer requires direct visualization and cannot be excluded by CT alone 1

When to Refer to Nephrology

Refer in addition to completing urologic evaluation if: 1, 2

• Dysmorphic RBCs >80% or red cell casts present 1, 2
• Protein-to-creatinine ratio >0.5 g/g 1
• Elevated serum creatinine or declining renal function 1, 2
• Hypertension accompanying hematuria and proteinuria 1, 2

Follow-Up if Initial Workup Is Negative

• Repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring at each visit 1, 4
• Immediate re-evaluation if gross hematuria develops, significant increase in microscopic hematuria, or new urologic symptoms appear 1, 4
• After two consecutive negative annual urinalyses, no further testing is necessary 1