Skip to Main Content

For further information, see CMDT Part 23-02: 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


  • 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


  • Should be directed to the underlying cause of the hematuria

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.