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Key Features

  • Both gross and microscopic hematuria require evaluation

  • The upper urinary tract should be imaged

  • Cystoscopy should be performed if there is hematuria in the absence of infection

  • Urinary cytology can be obtained after initial negative imaging and cystoscopic evaluation, and the cystoscopy and upper tract imaging repeated after 1 year

Clinical Findings

  • If gross hematuria occurs, a description of the timing (initial, terminal, total) may provide a clue to the localization of disease

  • Associated symptoms

    • Renal colic

    • Irritative voiding symptoms

    • Constitutional symptoms

  • Signs of systemic disease

    • Fever

    • Rash

    • Lymphadenopathy

    • Abdominal or pelvic masses

  • Signs of medical kidney disease

    • Hypertension

    • Volume overload

  • Urologic evaluation may demonstrate

    • Enlarged prostate

    • Flank mass

    • Urethral disease


  • Urinalysis and urine culture

  • Urine cytology, or other urinary-based markers, is not routinely recommended in the evaluation of asymptomatic microscopic hematuria

  • Abdominal and pelvic CT scanning without and with contrast) should be done to identify

    • Neoplasms of the kidney or ureter

    • Benign conditions such as urolithiasis, obstructive uropathy, papillary necrosis, medullary sponge kidney, or polycystic kidney disease

  • Cystoscopy

    • Can be used to assess for

      • Bladder or urethral neoplasm

      • Benign prostatic enlargement

      • Radiation or chemical cystitis

    • Indications

      • Gross hematuria

      • Presence of asymptomatic microscopic hematuria in patients > 35 years old

    • Best performed while patient is actively bleeding to allow better localization


  • Should be directed to the underlying cause of the hematuria

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