Hematuria

Key Features

• Both gross and microscopic hematuria require evaluation

• In microscopic hematuria, the workup should be risk stratified

• The history should obtain information regarding

  • Risk factors for urothelial cancer

    • Age

    • Male sex

    • Smoking

    • History of gross hematuria

    • Irritative lower urinary tract voiding symptoms

    • History of cyclophosphamide or ifosfamide chemotherapy

    • Family history of urothelial carcinoma or Lynch syndrome

    • Occupational exposure to benzene chemicals or aromatic amines

    • History of chronic indwelling foreign body in the urinary tract

  • Nonmalignant causes

• The upper urinary tract should be imaged

• The lower tract should be evaluated by cystoscopy

• 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

Diagnosis

• Patients with gross hematuria should have both complete evaluation of the upper tract by a CT-intravenous pyelogram (CT-IVP), or a magnetic resonance urogram (MR-urogram) with and without contrast

• The American Urological Association classifies microhematuria as low-, medium-, and high risk for a urothelial malignancy

  • Low-risk patients:

    • Repeat urinalyses over the next 6 months or proceed with cystoscopy and renal ultrasound

    • If microscopic hematuria persists on a repeat urinalysis, patients should be reclassified as intermediate- or high-risk and undergo both upper tract imaging according to their risk group, and lower tract evaluation by cystoscopy

  • Intermediate-risk patients: should undergo both upper tract imaging with renal ultrasound and lower tract evaluation by cystoscopy

  • High-risk patients:

    • Should undergo upper tract evaluation with CT-IVP (preferred), MR-urogram (if CT-IVP contraindicated) and cystoscopic evaluation of the bladder

    • If there are contraindications to CT-IVP and MR-urogram, clinicians may perform noncontrast axial imaging along with retrograde pyelography at the time of cystoscopy

• Cystoscopy is done to evaluate the bladder

Treatment

• Should be directed to the underlying cause of the hematuria