In a male patient with microscopic hematuria (3‑4 red blood cells per high‑power field) and pyuria (~25 white blood cells per high‑power field) on urinalysis and a hemoglobin of 10.5 g/dL, what is the appropriate initial evaluation and management?

Evaluation and Management of Microscopic Hematuria with Leukocytosis and Anemia

Immediate Priority: Rule Out Urinary Tract Infection

Obtain a urine culture immediately before initiating any antibiotics, as the elevated WBC count (24.97) combined with 3-4 RBCs/HPF raises concern for urinary tract infection. 1, 2

• If the patient has fever (>37.8°C), rigors, or systemic signs of infection, empiric antibiotics are appropriate while awaiting culture results 1
• If the patient is afebrile without systemic symptoms, defer antibiotics until culture results return 1
• Critical pitfall: Negative nitrite on dipstick does NOT exclude UTI—nitrite testing has only 53% sensitivity 1

Confirm True Microscopic Hematuria

Verify hematuria with formal microscopic urinalysis showing ≥3 RBCs per high-power field on a properly collected clean-catch midstream specimen, as dipstick testing alone has only 65-99% specificity. 1, 3

• 3-4 RBCs/HPF meets the diagnostic threshold for microscopic hematuria 1, 4
• This level falls into the low-risk category (3-10 RBC/HPF) for malignancy risk (0-0.4%) 4

Address the Anemia (Hemoglobin 10.5 g/dL)

The anemia requires separate evaluation and is unlikely to be caused by microscopic hematuria alone—investigate for other sources of blood loss or bone marrow suppression. 1

• Obtain complete blood count with differential, reticulocyte count, iron studies, and peripheral smear 1
• Consider gastrointestinal blood loss, chronic disease, nutritional deficiencies, or bone marrow disorders 1
• The combination of anemia + leukocytosis + hematuria suggests possible systemic infection or inflammatory process 1

Differentiate Glomerular vs. Urologic Source

Examine urinary sediment for dysmorphic RBCs and red cell casts to distinguish between glomerular and non-glomerular bleeding. 1, 2

Glomerular indicators (warrant nephrology referral):

• 80% dysmorphic RBCs on microscopy 1, 2

• Red cell casts (pathognomonic for glomerular disease) 1, 2
• Significant proteinuria (protein-to-creatinine ratio >0.5 g/g) 1, 2
• Elevated serum creatinine or declining renal function 1, 2
• Tea-colored or cola-colored urine 1

Urologic indicators (warrant urologic evaluation):

• 80% normal-shaped (isomorphic) RBCs 1

• Minimal or no proteinuria 1
• Age >40 years (males) or >50 years (females) 1, 4

Risk Stratification for Urologic Malignancy

Even though 3-4 RBCs/HPF is low-risk, patient age and other risk factors determine the need for urologic evaluation. 1, 4

High-risk features requiring cystoscopy + CT urography:

• Age ≥60 years (either sex) 1, 4
• Smoking history >30 pack-years 1, 4
• Any history of gross hematuria (even if self-limited) 1, 4
• Occupational exposure to benzenes or aromatic amines 1, 4
• Irritative voiding symptoms without documented infection 1, 4

Intermediate-risk features (shared decision-making):

• Males age 40-59 years 1, 4
• Females age 50-59 years 1, 4
• Smoking history 10-30 pack-years 1, 4

Low-risk features (may defer extensive imaging):

• Males <40 years 1, 4
• Females <50 years 1, 4
• Never smoker or <10 pack-years 1, 4
• 3-10 RBC/HPF 4

Post-UTI Management Algorithm

If urine culture is positive, treat appropriately and repeat urinalysis 6 weeks after completing antibiotics to confirm resolution of hematuria. 1, 2

• If hematuria resolves after treating infection in a low-risk patient, no further urologic workup is needed 1, 2
• If hematuria persists 6 weeks post-treatment, proceed with complete urologic evaluation regardless of risk category 1, 2
• Never attribute persistent hematuria to infection alone—malignancy can coexist with UTI 1

If No Infection Is Found

Proceed directly to risk-stratified evaluation based on patient age and risk factors outlined above. 1, 4

• High-risk patients: multiphasic CT urography + flexible cystoscopy 1
• Intermediate-risk patients: shared decision-making regarding cystoscopy/imaging 1, 4
• Low-risk patients: repeat urinalysis in 6 months or proceed with evaluation based on patient preference 1, 4

Common Pitfalls to Avoid

• Do not attribute hematuria to anticoagulation or antiplatelet therapy—these medications unmask underlying pathology but do not cause hematuria 1, 3
• Do not delay evaluation in patients >35-40 years—age alone is sufficient justification for complete urologic workup 1, 3
• Do not rely solely on dipstick testing—microscopic confirmation is mandatory 1, 3
• Do not assume the leukocytosis explains the hematuria—both require independent evaluation 1

Follow-Up Protocol

If initial workup is negative but hematuria persists, repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring at each visit. 1, 2

• After two consecutive negative annual urinalyses, further testing is unnecessary 1
• Immediate re-evaluation is warranted if gross hematuria develops, microscopic hematuria markedly increases, new urologic symptoms appear, or hypertension/proteinuria emerges 1, 2