Evaluation and Management of Hematuria in Adult Males
All adult males with confirmed hematuria (≥3 RBCs/HPF on microscopic examination) require systematic risk stratification and, in most cases, complete urologic evaluation with cystoscopy and upper tract imaging to exclude malignancy. 1, 2
Step 1: Confirm True Hematuria
- Never rely on dipstick testing alone—it has only 65–99% specificity and produces false positives from myoglobin, hemoglobin, menstrual blood, or other contaminants. 2, 3
- Obtain microscopic urinalysis on a properly collected clean-catch midstream specimen showing ≥3 red blood cells per high-power field (RBC/HPF) to confirm true hematuria. 1, 2
- For gross (visible) hematuria, proceed immediately to urgent urologic referral—this carries a 30–40% risk of malignancy and requires evaluation even if self-limited. 2, 4
Step 2: Exclude Transient Benign Causes
Before proceeding with invasive workup, rule out temporary causes: 5, 3
- Recent vigorous exercise 5
- Recent sexual activity 5
- Viral illness 5
- Trauma 3
- Urinary tract infection (UTI)—if suspected, obtain urine culture before starting antibiotics, treat appropriately, then repeat urinalysis 6 weeks after treatment completion to confirm resolution. 5, 3
If hematuria resolves after treating a benign cause in a low-risk patient, no further workup is needed. 5 However, if hematuria persists after 6 weeks post-treatment or the patient has high-risk features, proceed with full evaluation. 5
Step 3: Risk Stratification (AUA/SUFU 2020 Guidelines)
High-Risk Features (mandate cystoscopy + CT urography): 1, 2, 3
- Age ≥60 years (men) 1, 2
- Smoking history >30 pack-years 1, 2
- >25 RBCs/HPF on urinalysis 1, 2
- Any history of gross hematuria, even if self-limited 1, 2
- Occupational exposure to benzenes, aromatic amines, or industrial chemicals/dyes 1, 2
- Irritative voiding symptoms (urgency, frequency, dysuria) without documented infection 1, 2
- History of urologic disorders or pelvic irradiation 3
Intermediate-Risk Features (shared decision-making for cystoscopy/imaging): 1, 3
Low-Risk Features (may defer extensive imaging but still requires follow-up): 1, 3
Important: Even a single properly collected specimen with ≥3 RBCs/HPF justifies full evaluation in high-risk patients. 2 For low-risk patients without concerning features, confirm hematuria on two of three properly collected specimens before proceeding. 2
Step 4: Distinguish Glomerular vs. Urologic Source
Glomerular Indicators (prompt nephrology referral in addition to urologic evaluation): 2, 5, 3
- >80% dysmorphic RBCs on urinary sediment 2, 3
- Red blood cell casts (pathognomonic for glomerular disease) 2, 3
- Significant proteinuria: spot urine protein-to-creatinine ratio >0.5 g/g (or >500 mg/24 hours) 2, 3
- Elevated serum creatinine or declining renal function 2, 3
- Tea-colored or cola-colored urine 2
- Hypertension accompanying hematuria 2, 3
Urologic Indicators (proceed with urologic evaluation): 2, 3
Critical pitfall: Even when glomerular features are present, complete the urologic evaluation—malignancy can coexist with medical renal disease. 2
Step 5: Complete Urologic Evaluation
Upper Tract Imaging:
- Multiphasic CT urography (unenhanced, nephrographic, and excretory phases) is the preferred imaging modality, offering 96% sensitivity and 99% specificity for renal cell carcinoma, transitional cell carcinoma, and urolithiasis. 2, 3
- Renal ultrasound alone is insufficient for comprehensive upper tract evaluation—it cannot reliably assess ureters, bladder mucosa, or detect small urothelial carcinomas. 2
- If CT is contraindicated (severe renal insufficiency or contrast allergy), use MR urography or renal ultrasound with retrograde pyelography as alternatives. 2
Lower Tract Evaluation:
- Flexible cystoscopy is mandatory for all males ≥40 years with microscopic hematuria or any patient with gross hematuria to directly visualize bladder mucosa, urethra, and ureteral orifices. 2, 3
- Bladder cancer accounts for 30–40% of gross hematuria cases and 2.6–4% of microscopic hematuria cases—imaging alone cannot exclude it. 2
- Flexible cystoscopy is preferred over rigid cystoscopy because it causes less pain while providing equivalent or superior diagnostic accuracy. 2, 3
Adjunctive Testing:
- Voided urine cytology should be obtained in high-risk patients (age >60 years, smoking >30 pack-years, occupational exposures) to detect high-grade urothelial carcinomas and carcinoma in situ. 2, 3
- Serum creatinine and BUN to assess renal function before contrast administration. 2
- Urine culture if infection is suspected—obtain before starting antibiotics. 2, 5
Step 6: Follow-Up Protocol After Negative Initial Evaluation
If the complete urologic workup is negative but hematuria persists: 1, 2, 5
- Repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring at each visit. 1, 2, 5
- After two consecutive negative annual urinalyses, further testing is generally unnecessary. 2
- Consider repeat comprehensive evaluation (cystoscopy + imaging) within 3–5 years for persistent hematuria in high-risk patients. 2, 5
Immediate Re-Evaluation Triggers: 1, 2, 5
- Development of gross hematuria 1, 2
- Significant increase in degree of microscopic hematuria 1, 2
- New urologic symptoms (irritative voiding, flank pain) 1, 2
- Emergence of hypertension, proteinuria, or evidence of glomerular bleeding 1, 2
Critical Pitfalls to Avoid
- Never ignore gross hematuria, even if self-limited—it carries a 30–40% malignancy risk and mandates urgent urologic referral. 2, 4
- Never attribute hematuria to anticoagulation or antiplatelet therapy without completing the full diagnostic workup—these agents may unmask underlying pathology but do not cause hematuria themselves. 2, 3
- Do not delay evaluation in males ≥40 years with confirmed hematuria, even if a benign cause is suspected—age alone is a sufficient risk factor for full workup. 2, 3
- Do not rely solely on dipstick testing—microscopic confirmation of ≥3 RBCs/HPF is required before initiating any further evaluation. 2, 3
- Do not dismiss intermittent hematuria as benign—cancer-related bleeding is often intermittent, and evaluation should proceed per AUA recommendations. 2
Special Populations
Males <40 Years:
- Generally considered low-risk, but high-grade microscopic hematuria (>25 RBCs/HPF) in men under 40 carries a 20% incidence of urologic malignancy and warrants cystoscopy. 6
- Any high-risk feature (smoking, occupational exposure, gross hematuria, irritative symptoms) mandates full evaluation regardless of age. 2, 3
Males ≥60 Years:
- Automatically classified as high-risk and require both cystoscopy and CT urography regardless of other factors. 2, 3
- Women ≥60 years with hematuria have higher case-fatality rates from bladder cancer and tend to present with more advanced disease, underscoring the need for equal vigilance across sexes. 2