Skip to Main Content

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android

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

Key Features

Essentials of Diagnosis

  • Gross hematuria requires evaluation

    • Upper urinary tract should be imaged

    • Lower urinary tract should be evaluated by cystoscopy

  • In microscopic hematuria, the workup should be risk stratified

  • General ConsiderationsAn upper tract source (kidneys and ureters) can be identified in 10% of patients with gross or microscopic hematuria

  • A lower tract source of gross hematuria (in the absence of infection) most commonly caused by

    • Bleeding prostatic varices

    • Urothelial carcinoma of the bladder

  • Microscopic hematuria in the male is most commonly due to

    • Benign prostatic hyperplasia (13%)

    • Kidney stones (6%)

    • Urethral stricture (1.4%)

  • Presence of hematuria in patients receiving antiplatelet or anticoagulation therapy

    • Cannot be presumed to be due to the medication

    • Warrants complete evaluation, consisting of

      • Upper tract imaging

      • Cystoscopy

      • Urine cytology

Clinical Findings


  • 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

Symptoms and Signs

  • 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


Laboratory Findings

  • Initial tests include a urinalysis and urine culture

  • Microhematuria is defined as three 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 kidney disease may influence the methods of further evaluation and management (eg, ability to obtain contrast imaging) of hematuria

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


  • 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 ...

Pop-up div Successfully Displayed

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