Evaluation and Management of Hematuria

Initial Assessment

The American College of Physicians recommends confirming the presence of hematuria with microscopic examination of urinary sediment from a freshly voided, clean-catch, midstream urine specimen, with a threshold of ≥3 red blood cells per high-power field 1
The American Urological Association suggests excluding benign causes, including infection, vigorous exercise, trauma, and medications, to determine the underlying cause of hematuria 3
Obtain urine culture to rule out urinary tract infection as a potential cause of hematuria, as recommended by the American College of Physicians 2
Assess for signs of primary renal disease, including significant proteinuria, dysmorphic red blood cells, red cell casts, or elevated serum creatinine, as suggested by the American College of Physicians 1

The American Urological Association recommends evaluation for patients with asymptomatic microscopic hematuria who are older than 35 years, as the risk of urologic malignancy increases with age 1
Assess for additional risk factors, including smoking history, occupational exposure to chemicals or dyes, history of gross hematuria, and irritative voiding symptoms, to determine the overall risk of malignancy 3
The risk of malignancy in patients with microscopic hematuria ranges from 2.6% to 4%, compared to 30-40% in those with gross hematuria, according to the American Urological Association 3

The American College of Physicians recommends urgent urologic referral for patients with gross hematuria due to the high risk of underlying malignancy (>10%) 3
Do not attribute hematuria solely to antiplatelet or anticoagulant therapy without further investigation, as recommended by the American College of Physicians 1
Assess for glomerular versus non-glomerular source of hematuria, as suggested by the American College of Physicians 1

The American College of Radiology recommends CT urography as the preferred imaging modality for comprehensive evaluation of the upper urinary tract 1
The American Urological Association suggests direct visualization of the bladder mucosa, urethra, and ureteral orifices through cystoscopy 3
Obtain serum creatinine to assess renal function, as recommended by the American College of Physicians 3

The American Urological Association recommends urologic referral for all patients with gross hematuria, patients with microscopic hematuria at age 36 with risk factors, or if no benign cause is identified 1
Consider nephrology referral if there is evidence of glomerular disease, such as proteinuria, red cell casts, or predominantly dysmorphic RBCs, as suggested by the American Society of Nephrology 3

Repeat urinalysis at 6, 12, 24, and 36 months if initial evaluation is negative, as recommended by the American Urological Association 3
Monitor blood pressure and consider nephrology referral if hematuria persists with development of hypertension, proteinuria, or evidence of glomerular bleeding, as suggested by the American Society of Nephrology 3
Immediate urologic reevaluation is warranted if any of the following occur: gross hematuria, abnormal urinary cytology, or irritative voiding symptoms in the absence of infection, as recommended by the American Urological Association 2

Do not attribute hematuria solely to antiplatelet or anticoagulant therapy without further investigation, as recommended by the American College of Physicians 1
Do not delay urologic referral while waiting for other test results in a patient with gross hematuria, as suggested by the American Urological Association 3
Do not assume that a single negative urinalysis excludes significant pathology, as hematuria from cancer can be intermittent, as recommended by the American College of Physicians 1