From the Guidelines
Gross hematuria requires immediate medical attention due to its high association with malignancy, with up to 30% to 40% of cases being related to cancer, as stated in the study by Wolfman et al 1. The diagnostic workup for gross hematuria typically includes:
- Urinalysis to confirm the presence of blood in the urine
- Urine culture to check for urinary tract infections
- Complete blood count and renal function tests to assess overall kidney function
- Imaging studies such as CT urography or ultrasound to visualize the urinary tract
- Cystoscopy may be necessary to directly visualize the bladder and urethra
Treatment depends entirely on the underlying cause, which may include:
- Urinary tract infections (treated with antibiotics like nitrofurantoin 100mg twice daily for 5-7 days or trimethoprim-sulfamethoxazole twice daily for 3 days)
- Kidney stones (managed with pain control, hydration, and possibly urological intervention)
- Bladder or kidney cancer
- Trauma
- Glomerular diseases
The American College of Physicians recommends that clinicians refer all adults with gross hematuria for further urologic evaluation, even if the hematuria is self-limited, as stated in the study by 1 and 1. While awaiting medical evaluation, patients should increase fluid intake to prevent clot formation and track any associated symptoms such as pain, fever, or changes in urination patterns. The presence of blood in urine indicates disruption somewhere in the urinary tract, from the kidneys to the urethra, and should never be ignored as early diagnosis of serious conditions like urological cancers significantly improves outcomes.
From the Research
Definition and Classification of Hematuria
- Hematuria is classified as either gross or microscopic 2
- Gross hematuria has a risk of malignancy greater than 10% 2
Causes of Gross Hematuria
- Painless atraumatic gross hematuria in the elderly is caused by a malignancy until proven otherwise 3
- Common causes of gross hematuria include infection, malignancy, and urolithiasis 4
Evaluation and Management of Gross Hematuria
- Patients with gross hematuria warrant a thorough history and physical to determine potential causes and assess risk factors for malignancy 2
- Prompt urologic referral is recommended for patients with gross hematuria 2
- Clinical evaluation of patients with gross hematuria often involves urological consultation with urine cytology, urine culture, imaging studies, and cystoscopy 4
Imaging Studies for Gross Hematuria
- Computed tomography urography is recognized to have significant advantages in evaluating the upper tracts in patients with hematuria 5
- Multidetector computed tomography urography is less susceptible to overlying bowel gas and more sensitive for detection of small tumors and calculi 5
- Ultrasound examination and magnetic resonance imaging can also be useful in specific cases, particularly in children and pregnant women 5