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For further information, see CMDT Part 23-02: Hematuria

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 an identifiable benign cause

  • Urinary cytology can be obtained after initial negative imaging and cystoscopic evaluation

  • If work-up is negative, the cystoscopy and upper tract imaging should be 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 to inquire about

    • 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

  • Microhematuria is defined as 3 or more red blood cells per high power field on a microscopic evaluation of the urine

  • A positive dipstick reading for heme merits microscopic examination to confirm or refute the diagnosis of hematuria but is not enough to warrant workup on its own

  • If urinalysis and culture is suggestive of a urinary tract infection, follow-up urinalysis after treatment of the infection is important to ensure resolution of the hematuria

  • An estimate of kidney function should be obtained since renal insufficiency may influence the methods of further evaluation (eg, ability obtain contrast imaging) and management of patients with hematuria

  • Urine cytology and other urinary-based markers are not routinely recommended in the evaluation of asymptomatic microscopic hematuria

  • CT-intravenous pyelogram (CT-IVP)

    • Upper tract should be imaged with no contrast, with contrast, and with excretory delayed imaging to identify neoplasms of the kidney or ureter as well as benign conditions such as

      • Urolithiasis

      • Obstructive uropathy

      • Papillary necrosis

      • Medullary sponge kidney

      • Polycystic kidney disease

  • A magnetic resonance urogram without and with contrast can be performed for patients with relative or absolute contraindications that preclude a CT-IVP, such as

    • Kidney disease

    • Intravenous contrast allergy

    • Pregnancy

  • Ultrasonographic evaluation of the urinary tract for hematuria

    • Role is unclear

    • Although it may provide adequate information about the kidney, its sensitivity in detecting ureteral disease is lower

  • Cystoscopy

    • Is necessary for

      • Bladder or urethral neoplasm

      • Benign prostatic hyperplasia

      • 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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