Evaluation and Management of Bladder Pain with Microhematuria

Initial Assessment

The American Urological Association (AUA) and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) recommend risk stratification using the 2025 AUA/SUFU criteria for patients with bladder pain and microhematuria, followed by cystoscopy and upper tract imaging for intermediate- or high-risk patients 1
A focused history should include smoking history, quantified as pack-years, as this is the strongest modifiable risk factor for urothelial malignancy 1
Age and sex are also important factors, with men ≥40 years and women ≥60 years having an elevated risk 1
Irritative voiding symptoms, such as urgency, frequency, and nocturia, may indicate interstitial cystitis or bladder cancer 2
Occupational exposures to benzenes, aromatic amines, or other chemical carcinogens should also be assessed 3
A history of gross hematuria, even if not currently present, is also relevant 1
Chronic pelvic pain patterns, particularly in women, should be evaluated as interstitial cystitis is often underdiagnosed 2
Physical examination should include blood pressure measurement to assess for renal parenchymal disease 1
Pelvic examination in women and rectal examination in men should be performed to exclude gynecologic and prostate causes, respectively 2
Serum creatinine should be obtained to evaluate renal function 1

Microscopic urinalysis is mandatory to confirm ≥3 RBCs/HPF, as dipstick alone has limited specificity and can yield false positives 4
If urinary tract infection is suspected, urine culture should be obtained before starting antibiotics, and urinalysis should be repeated 6 weeks post-treatment 2, 5
Benign causes, such as menstruation, vigorous exercise, sexual activity, and recent urologic procedures, should be excluded by repeating urinalysis 48 hours after cessation of these activities 2, 3

Patients should be categorized as low/negligible risk, intermediate risk, or high risk based on the 2025 AUA/SUFU criteria 1
Low/negligible risk patients have a malignancy risk of 0-0.4%, while intermediate risk patients have a malignancy risk of 0.2-3.1%, and high risk patients have a malignancy risk of 1.3-6.3% 4

For intermediate or high-risk patients, cystoscopy is mandatory to visualize the bladder and urethra 1, 2
Upper tract imaging, preferably CT urography, should be performed to evaluate for urologic pathology 2
Urine cytology should be obtained in patients with risk factors for transitional cell carcinoma 7, 5

Bladder pain with hematuria may indicate interstitial cystitis, particularly in women with chronic pelvic pain 2
Key features of interstitial cystitis include irritative voiding symptoms and pelvic/bladder pain 2

If initial evaluation is negative but hematuria persists, repeat urinalysis should be performed at 6, 12, 24, and 36 months 3
Blood pressure should be monitored at each visit 3
Nephrology referral should be considered if hematuria persists with development of hypertension, proteinuria, or evidence of glomerular bleeding 3