Evaluation and Management of Hematuria

Definition and Initial Assessment

Microscopic hematuria is defined as three or more red blood cells per high-power field on microscopic evaluation of urinary sediment from two of three properly collected urinalysis specimens, according to the American Academy of Family Physicians 1
Dipstick detection of hematuria should always be confirmed with microscopic examination due to limited specificity (65-99%), as recommended by the American Academy of Family Physicians 1
Initial evaluation should include assessment of renal function (eGFR, creatinine, BUN), as suggested by the American Urological Association 2
The American Academy of Family Physicians recommends determining if the hematuria is associated with risk factors for significant disease, including smoking history, occupational exposure to chemicals or dyes, history of gross hematuria, age > 40 years, previous urologic disorder or disease, history of irritative voiding symptoms, history of urinary tract infection, and analgesic abuse 4
A history of pelvic irradiation is also a risk factor for hematuria, according to the American Academy of Family Physicians 1

The American Academy of Family Physicians suggests evaluating for signs of glomerular disease, including the presence of RBC casts, which are virtually pathognomonic for glomerular bleeding 5
Significant proteinuria (>1g/day) is also a sign of glomerular disease, as noted by the American College of Physicians 3
Elevated serum creatinine is another indicator of glomerular disease, according to the American Urological Association 2
Dysmorphic RBCs show variation in size and shape with irregular or distorted outlines, suggesting glomerular origin, as described by the American Academy of Family Physicians 5
Normal doughnut-shaped RBCs generally indicate lower urinary tract bleeding, according to the American Academy of Family Physicians 5

If dysmorphic RBCs, proteinuria, cellular casts, or renal insufficiency are present, concurrent nephrologic evaluation is warranted, as recommended by the American Urological Association and the American College of Physicians 2, 3
Quantify proteinuria with 24-hour urine collection (significant if >1g/day), as suggested by the American College of Physicians 3
Evaluate for systemic diseases associated with glomerulonephritis, according to the American College of Physicians 3
Consider renal biopsy when systemic causes are not identified, as recommended by the American College of Physicians 3
Monitor renal function, proteinuria levels, and blood pressure, as suggested by the American College of Physicians 3

Complete urologic evaluation includes history and physical examination, laboratory analysis, radiologic imaging of upper urinary tract, and cystoscopic examination, as recommended by the American Academy of Family Physicians 4
Cystoscopy should be performed on all patients aged 35 years and older, according to the American Urological Association 2
Cystoscopy may be performed at physician's discretion in patients younger than 35, as suggested by the American Urological Association 2
Cystoscopy should be performed regardless of age in patients with risk factors for urinary tract malignancies, according to the American Urological Association 2
Multi-phasic CT urography is the imaging procedure of choice, as recommended by the American Urological Association 2

Patients on anticoagulation therapy require both urologic and nephrologic evaluation regardless of the type or level of anticoagulation, according to the American Urological Association 2
Do not attribute hematuria solely to anticoagulation therapy when cellular casts and significant proteinuria are present, as noted by the American College of Physicians 3
For patients with benign causes (menstruation, vigorous exercise, sexual activity, viral illness, trauma, infection), repeat urinalysis 48 hours after cessation of the activity, as recommended by the American Academy of Family Physicians 4
In women, urethral and vaginal examinations should be performed to exclude local causes, according to the American Academy of Family Physicians 4
In uncircumcised men, the foreskin should be retracted, and catheterized specimen may be required if phimosis is present, as suggested by the American Academy of Family Physicians 4

Patients with urinary tract infection should be treated appropriately and urinalysis repeated six weeks after treatment, as recommended by the American Academy of Family Physicians 4
Patients with glomerular disease require monitoring of proteinuria levels, blood pressure, and renal function, according to the American College of Physicians 3
For patients with isolated hematuria and negative initial evaluation, repeat urinalysis and blood pressure checks at 6, 12, 24, and 36 months, as suggested by the American College of Physicians 6