Hematuria Workup in Adults
Confirm True Hematuria First
Do not initiate any workup based on dipstick alone—microscopic confirmation showing ≥3 RBCs per high-power field (RBC/HPF) on a properly collected clean-catch midstream specimen is mandatory before proceeding. 1
- Dipstick testing has only 65-99% specificity and produces false positives from myoglobin, hemoglobin, menstrual contamination, or other substances 1
- For patients without high-risk features, confirm hematuria on at least 2 of 3 properly collected specimens before initiating extensive evaluation 1
- For patients with high-risk features (see below), a single specimen with ≥3 RBC/HPF may be sufficient to trigger full evaluation 1
Immediate Triage: Gross vs. Microscopic Hematuria
Gross (Visible) Hematuria
All patients with gross hematuria require urgent urologic referral (within 24-48 hours) with cystoscopy and upper tract imaging, regardless of age, sex, or whether bleeding is self-limited—this carries a 30-40% malignancy risk. 1
- This recommendation applies even if the patient is on anticoagulation or antiplatelet therapy, as these medications unmask rather than cause hematuria 1
- Gross hematuria with clots mandates immediate hemodynamic assessment and urgent urologic consultation 1
Microscopic Hematuria
Proceed with risk stratification (see below) to determine extent of evaluation 1
Risk Stratification for Microscopic Hematuria
High-Risk Features (Require Full Urologic Workup: Cystoscopy + CT Urography)
- Age ≥60 years (both men and women) 1
- Smoking history >30 pack-years 1
- Any prior episode of gross hematuria, even if self-limited 1
- Occupational exposure to benzenes, aromatic amines, or other bladder carcinogens 1
- Irritative voiding symptoms (urgency, frequency, dysuria) without documented infection 1
- Degree of hematuria >25 RBC/HPF 1, 2
Intermediate-Risk Features (Shared Decision-Making)
- Men aged 40-59 years or women aged 50-59 years 1
- Smoking history 10-30 pack-years 1
- Hematuria 11-25 RBC/HPF 1
Low-Risk Features (May Defer Extensive Imaging)
Distinguish Glomerular from Urologic Source
Glomerular Indicators (Require Nephrology Referral in addition to urologic evaluation)
- >80% dysmorphic RBCs on phase-contrast microscopy 1
- Red blood cell casts (pathognomonic for glomerular disease) 1, 2
- Significant proteinuria: spot urine protein-to-creatinine ratio >0.5 g/g 1
- Tea-colored or cola-colored urine 1
- Elevated serum creatinine or declining renal function 1
- Hypertension accompanying hematuria and proteinuria 1
Critical pitfall: The presence of glomerular features does not eliminate the need for urologic evaluation—malignancy can coexist with medical renal disease 1
Urologic Indicators
- Normal-shaped RBCs (>80%) with minimal or no proteinuria 1
- Bright red blood in urine (suggests lower urinary tract) 1
- Flank pain, suprapubic pain, or dysuria 1
Complete Urologic Evaluation (for High-Risk or Persistent Hematuria)
Upper Tract Imaging
Multiphasic CT urography is the preferred modality, including unenhanced, nephrographic, and excretory phases—this provides 96% sensitivity and 99% specificity for detecting renal cell carcinoma, transitional cell carcinoma, and urolithiasis 1
- Alternative imaging (if CT contraindicated): MR urography or renal ultrasound with retrograde pyelography 1
- Renal ultrasound alone is insufficient for comprehensive upper tract evaluation 1
Lower Tract Evaluation
Flexible cystoscopy is mandatory for all patients with:
- Gross hematuria (any age) 1
- Microscopic hematuria in patients ≥40 years 1
- Any patient with high-risk features 1
Flexible cystoscopy is preferred over rigid cystoscopy—it causes less pain with equivalent or superior diagnostic accuracy 1
Laboratory Testing
- Serum creatinine and BUN to assess renal function 1
- Complete urinalysis with microscopy examining for dysmorphic RBCs, casts, and degree of proteinuria 1
- Spot urine protein-to-creatinine ratio if proteinuria is present 1
- Urine culture if infection is suspected—obtain before starting antibiotics 1
Adjunctive Testing
- Voided urine cytology may be considered in high-risk patients (age >60, smoking >30 pack-years, occupational exposures) to detect high-grade urothelial carcinomas 1
- Do not use urine cytology or molecular markers as the initial or sole evaluation tool 1
Special Clinical Scenarios
Hematuria with Urinary Tract Infection
- Obtain urine culture before antibiotics 1
- If hematuria resolves within 6 weeks after treating infection in a low-risk patient, no further workup is needed 1
- If hematuria persists after infection treatment, proceed immediately with full urologic evaluation 1
- Never defer evaluation in patients ≥40 years or those with high-risk features, even if UTI is present—infection does not exclude malignancy 1
Hematuria in Patients on Anticoagulation/Antiplatelet Therapy
Do not attribute hematuria to anticoagulation or antiplatelet therapy—these medications may unmask underlying pathology but do not cause hematuria themselves, and evaluation must proceed regardless. 1
Hematuria with Benign Prostatic Hyperplasia
- BPH can cause hematuria but does not exclude concurrent malignancy 1
- Gross hematuria from BPH must be proven to be of prostatic etiology through appropriate evaluation 1
Follow-Up Protocol After Negative Initial Evaluation
If the complete urologic workup is negative but hematuria persists:
- Repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring at each visit 1
- After two consecutive negative annual urinalyses, further testing is unnecessary 1
- Consider repeat complete evaluation within 3-5 years for persistent hematuria in high-risk patients 1
Triggers for Immediate Re-Evaluation
- Development of gross hematuria 1
- Significant increase in degree of microscopic hematuria 1
- New urologic symptoms (irritative voiding, flank pain) 1
- Development of hypertension, proteinuria, or evidence of glomerular bleeding 1
Pediatric Considerations
- Children with isolated microscopic hematuria without proteinuria or dysmorphic RBCs do not require imaging—clinical follow-up is appropriate 1, 2
- Gross hematuria in children requires renal and bladder ultrasound to exclude nephrolithiasis, anatomic abnormalities, and rarely tumors 1
- CT is not appropriate in the initial evaluation of isolated nonpainful, nontraumatic hematuria in children 1, 2
- Renal ultrasound is the preferred modality in children to assess anatomy before potential renal biopsy 1
Critical Pitfalls to Avoid
- Never ignore gross hematuria, even if self-limited—30-40% malignancy risk mandates urgent urologic referral 1
- Never rely solely on dipstick testing—confirm with microscopic urinalysis showing ≥3 RBCs/HPF 1
- Never defer evaluation due to anticoagulation—these medications unmask rather than cause hematuria 1
- Never assume age <40 years means benign disease if high-risk features are present (smoking, occupational exposure, prior gross hematuria, irritative symptoms) 1
- Never attribute persistent hematuria to a treated UTI without completing full urologic evaluation in patients ≥40 years 1
- Never perform urologic workup without first confirming ≥3 RBC/HPF on microscopy—this prevents unnecessary radiation, invasive procedures, and costs 1