One-liner#

Blood in urine—gross or microscopic—requires systematic evaluation to rule out malignancy, with workup intensity based on risk factors and presentation.

Quick nav#

• Red flags / send to ED
• Key history
• Focused exam
• Differential (quick pattern recognition)
• Workup
• Initial management
• Management by diagnosis
• Follow-up
• Patient instructions
• Smartphrase snippets

Red flags / send to ED#

• Gross hematuria with clots and urinary retention → may need bladder irrigation; urology consult
• Gross hematuria + hemodynamic instability → significant blood loss; ED for resuscitation
• Flank pain + fever + hematuria → infected obstructing stone (pyonephrosis); urologic emergency
• Trauma + hematuria → imaging needed to rule out renal/bladder injury
• Anticoagulated patient with significant gross hematuria → may need reversal, urology evaluation

Key history#

Characterize the hematuria:

• Gross (visible) vs microscopic (found on UA)
• Timing: throughout void (bladder/kidney) vs initial (urethral) vs terminal (bladder neck/prostate)
• Clots present? (suggests significant bleeding)
• Duration and frequency of episodes
• Color: pink, red, tea-colored, cola-colored

Associated symptoms:

• Dysuria, frequency, urgency → UTI, cystitis
• Flank pain → stone, pyelonephritis, renal mass
• Colicky pain → nephrolithiasis
• Weight loss, fatigue → malignancy concern
• Joint pain, rash, recent URI → glomerulonephritis

Risk factors for urologic malignancy (AUA criteria):

• Age >60 (risk increases with age)
• Male sex
• Smoking history (current or past)
• Occupational exposures (dyes, rubber, chemicals)
• Gross hematuria
• Prior pelvic radiation
• Cyclophosphamide exposure
• Chronic UTIs or indwelling catheter
• Family history of urothelial cancer or Lynch syndrome

Benign causes to consider:

• Menstruation (contamination)
• Recent vigorous exercise
• Recent sexual activity
• Recent urologic procedure
• Medications: anticoagulants, NSAIDs (don’t cause hematuria but unmask underlying pathology)

Medication review:

• Anticoagulants (warfarin, DOACs, heparin)
• Antiplatelet agents
• NSAIDs
• Medications causing red urine (rifampin, phenazopyridine, beets)

Focused exam#

Vital signs:

• Fever → infection
• Hypertension → consider renal parenchymal disease

Abdominal exam:

• Flank/CVA tenderness → pyelonephritis, stone, renal mass
• Suprapubic tenderness → cystitis
• Palpable bladder → retention
• Abdominal mass → renal tumor (rare to palpate)

GU exam:

• Men: urethral meatus (blood at meatus suggests urethral injury), prostate exam (enlarged, nodular)
• Women: pelvic exam if vaginal source suspected, urethral caruncle

Other:

• Edema → nephrotic syndrome, renal failure
• Skin: rash, petechiae → vasculitis, bleeding disorder
• Joints: arthritis → lupus, IgA nephropathy

Differential (quick pattern recognition)#

Common/likely (outpatient)#

Can’t-miss / urgent#

Workup#

Initial evaluation (all patients with hematuria):

• Confirm hematuria: UA with microscopy (>3 RBCs/HPF = microscopic hematuria)
• Assess for UTI: if pyuria/bacteriuria present, treat and repeat UA in 6 weeks
• BMP: assess renal function
• Urine cytology: low sensitivity (~40% for high-grade tumors); often ordered by urology but not required for initial PCP workup

Imaging notes:

• CT urogram = CT without contrast PLUS CT with contrast (evaluates kidneys, ureters, bladder)
• Renal US = adequate for low-risk patients; misses ureteral lesions
• CT non-contrast = best for stones; does not evaluate for soft tissue masses

Risk stratification (AUA 2020 guidelines):

Low risk (all must be present):

• Women age <50, men age <40
• Never smoker or <10 pack-years quit >30 years ago
• 3-10 RBCs/HPF on single UA
• No other risk factors

Intermediate risk:

• Women 50-59, men 40-59
• 10-30 pack-year history
• 11-25 RBCs/HPF
• Low-risk with persistent microhematuria on repeat UA

High risk (any of the following):

• Age >60

• 30 pack-year smoking history

• 25 RBCs/HPF

• Gross hematuria
• History of gross hematuria

Workup by risk:

• Low risk: Repeat UA in 6 months; if persistent, cystoscopy + renal US
• Intermediate risk: Cystoscopy + renal US (CT urogram if high suspicion)
• High risk: Cystoscopy + CT urogram

Glomerular vs non-glomerular hematuria:

• Glomerular: dysmorphic RBCs, RBC casts, significant proteinuria, brown/tea-colored urine
• Non-glomerular: isomorphic RBCs, no casts, minimal proteinuria, red/pink urine with clots

If glomerular source suspected:

• Urine protein/creatinine ratio
• BMP (renal function)
• Consider: ANA, C3/C4, ANCA, anti-GBM, hepatitis B/C, HIV
• Nephrology referral

When NOT to order:

• Do NOT skip malignancy workup because patient is on anticoagulation—anticoagulants unmask pathology, they don’t cause it
• Do NOT attribute hematuria to “just BPH” without cystoscopy in high-risk patients
• Do NOT repeat UA during menstruation or within 48 hours of vigorous exercise

Initial management#

UTI-associated hematuria:

• Treat UTI
• Repeat UA 6 weeks after treatment
• If hematuria persists, proceed with malignancy workup

Suspected nephrolithiasis:

• Pain control (NSAIDs first-line if no contraindication)
• Alpha-blocker for distal stones <10mm (medical expulsive therapy)
• Strain urine for stone analysis
• Urology referral if: stone >10mm, not passing after 4-6 weeks, infection, intractable pain

Gross hematuria with clots:

• Urology referral (may need cystoscopy, bladder irrigation)
• If hemodynamically unstable or retention, send to ED

Anticoagulated patient:

• Do NOT stop anticoagulation without cardiology input
• Still requires full malignancy workup
• Urology referral for cystoscopy

Suspected glomerulonephritis:

• Nephrology referral
• Blood pressure control
• Avoid NSAIDs

Management by diagnosis#

Microscopic Hematuria (Asymptomatic)#

Education:

• Blood in urine found on routine testing
• Usually benign but needs evaluation to rule out serious causes
• Workup depends on risk factors

PCP role:

• Risk stratify per AUA guidelines
• Order appropriate imaging
• Refer to urology for cystoscopy when indicated
• If workup negative, periodic monitoring

Follow-up: Per risk category; if negative workup, repeat UA annually x 2 years.

UTI with Hematuria#

Education:

• Blood in urine is common with bladder infections
• Should resolve after treating the infection
• Need to recheck urine after treatment to make sure blood is gone

Treatment: See dysuria page for UTI management.

Follow-up: Repeat UA 6 weeks after treatment. If hematuria persists, full malignancy workup regardless of age.

Nephrolithiasis#

Education:

• Kidney stone causing blood in urine
• Most small stones pass on their own
• Drink plenty of fluids; strain urine to catch stone
• Pain can be severe but manageable with medication

Treatment:

Urology referral indications:

• Stone >10mm
• Not passing after 4-6 weeks
• Infection with obstruction (emergency)
• Intractable pain or vomiting
• Solitary kidney
• Bilateral obstructing stones

Follow-up: 2-4 weeks to confirm stone passage. If passed, 24-hour urine for metabolic evaluation if recurrent stones.

BPH with Hematuria#

Education:

• Enlarged prostate can cause blood in urine
• Still need to rule out bladder cancer with cystoscopy
• BPH treatment may reduce bleeding episodes

PCP role:

• Check PSA
• Refer to urology for cystoscopy (cannot assume BPH is the cause)
• Manage BPH symptoms (see urinary frequency page)

Follow-up: Urology manages after cystoscopy.

Bladder Cancer (Suspected or Confirmed)#

Recognition:

• Painless gross hematuria in older patient
• Smoking history significantly increases risk
• May have irritative voiding symptoms

PCP role:

• Recognize and refer urgently to urology
• Do NOT delay referral for “observation”
• Support patient through diagnostic process

Referral: Urgent urology (within 2 weeks for gross hematuria).

Glomerulonephritis#

Recognition:

• Tea/cola-colored urine
• Dysmorphic RBCs, RBC casts on microscopy
• Proteinuria, edema, hypertension
• May follow URI (post-streptococcal, IgA nephropathy)

PCP role:

• Recognize glomerular pattern
• Check BMP, urine protein/creatinine ratio
• Refer to nephrology
• Blood pressure control (ACE inhibitor/ARB preferred)
• Avoid NSAIDs

Referral: Nephrology; urgent if rapidly progressive (rising creatinine).

Follow-up#

Negative initial workup:

• Low risk: Repeat UA in 6 months, then annually x 2 years
• Intermediate/high risk: Consider repeat cystoscopy in 1 year if high suspicion

Persistent microscopic hematuria with negative workup:

• Annual UA for at least 2 years
• Re-evaluate if gross hematuria develops or risk factors change
• Consider nephrology referral if proteinuria develops

After UTI treatment:

• Repeat UA in 6 weeks
• If hematuria persists, full workup

Return precautions:

• Gross hematuria (if previously only microscopic)
• Clots in urine
• Difficulty urinating
• Flank pain, fever
• Unintentional weight loss

Patient instructions#

• Blood in your urine needs to be evaluated, even if you feel fine
• We need to make sure there’s no serious cause like a bladder or kidney problem
• You may need a scan of your kidneys and a scope to look inside your bladder
• If you smoke, this is a good time to quit—smoking increases the risk of bladder cancer
• Call or return if: you see more blood, have pain, fever, trouble urinating, or can’t urinate at all
• Drink plenty of water unless told otherwise

Smartphrase snippets#

Microscopic hematuria workup: “Microscopic hematuria identified on UA ([X] RBCs/HPF). Risk stratified per AUA guidelines as [low/intermediate/high] risk. Plan: [repeat UA in 6 months / renal US + urology referral for cystoscopy / CT urogram + urology referral]. Patient counseled on importance of completing workup to rule out malignancy.”

Gross hematuria referral: “Gross hematuria without clear infectious etiology. Given [age/smoking history/risk factors], urgent urology referral placed for cystoscopy and upper tract imaging. Patient advised to go to ED if develops clots, retention, or hemodynamic symptoms.”

Hematuria with UTI: “Hematuria in setting of symptomatic UTI. Treated with [antibiotic]. Will repeat UA in 6 weeks after treatment completion. If hematuria persists, will proceed with malignancy workup regardless of age. Return precautions given.”

Related pages#

• Benign Prostatic Hyperplasia (problem) — BPH can cause hematuria; requires malignancy workup regardless
• Chronic Kidney Disease (problem) — glomerular hematuria may indicate CKD; nephrology referral criteria