Gross Hematuria

Hematuria – presence of >3 RBCs /hpf on urine microscopy

  • In adults, suspect urologic malignancy until proven otherwise
  • All patients, except young females with acute bacterial hemorrhagic cystitis, should have urologic evaluation
  •  Most common cause of gross hematuria in patients > 50 yrs = bladder cancer

Causes of hematuria

  • Prerenal
    • Coagulopathy (hemophilia, ITP)
    • Anticoagulation
    • Collagen vascular disease (SLE, scleroderma)
    • Sickle cell disease
  • Renal
    • Glomerular
      • Gomerulonephritis
      • Lupus nephritis
      • Benign familial hematuria
      • Alport’s syndrome
      • Vascular abnormalities
    • Nonglomerular
      • Pyelonephritis
      • Granulomatous disease (TB, cryptococcosis)
      • Xanthogranulomatous pyelonephritis
      • Interstitial nephritis
      • Papillary necrosis
      • Neoplasm (RCC)
  • Postrenal
    • Calculus
    • Ureteritis
    • Cystitis
    • Prostatitis
    • BPH
    • Epididymitis
    • Urethritis
    • Neoplasm (TCC)
  • False
    • Vaginal bleeding
    • Recent circumcision
    • Factitious
    • Pigmenturia (myoglobinuria, hemoglobinuria, porphyria; foods – beets, blackberries; drugs – rifampin, quinine sulphate)


Most common causes by age group:

AGE                CAUSE

0 -20                glomerulonephritis, UTI, congenital anomalies

20-40               UTI, stones, bladder tumor

40-60               ♂: bladder tumor, calculi, UTI

♀: UTI, calculi, bladder tumor

>60                  ♂: BPH, bladder tumor, UTI

♀: bladder tumor, UTI


Characterize the hematuria:

  • Is the blood visible or was it found on microscopy? (more likely to find cause of gross hematuria)
  • At what point during urination is the blood seen? (initial – urethra; total – bladder or upper tract; terminal – bladder neck or prostatic urethra)
  • Associated with pain? (can be due to cystitis, stone, or upper tract hematuria with obstruction of the ureters by clots)
  • Are there any clots? (indicates more significant degree of hematuria)
  • Do clots have a specific shape? (vermiform clots assoc’d with flank pain suggests upper tract origin)
  • Systemic symptoms: fever, rash, joint pain (SLE), weight loss, night sweats
  • Recent trauma, menstruation (endometriosis), sexual activity, infection (URTI, pharyngitis, skin infection, or rash + hematuria Þ poststreptococcal glomerulonephritis)
  • Exercise
  • Ingestion of drugs or foods that cause pseudohematuria

Meds:  – NSAIDS, anticoagulants

PMHx:            – calculi, flank pain, CA, infxns, renal disease, pelvic radiation

FHx:   – renal disease (likely a glomerular leak), DM, sickle cell anemia, polycystic kidney disease, calculi

SHx:    – smoking, occupational and environmental exposures (dyes, rubber compounds)

Physical Examination:

  • General – cachexia
  • Vitals – blood pressure, T, fluid status
  • Abdomen – mass or tenderness
  • GU – external genitalia; DRE in male >50


  • CBC (anemia, leukocytosis), lytes, BUN, Cr
  • Urine C&S, R&M; cytology
  • Renal/ bladder US (renal US = initial test for upper tracts)
  • CT (upper tracts)
  • Cystoscopy +/- retrograde pyelogram (bladder/ ureters)
  • Bladder tumor assays

If initial evaluation is negative & persistent hematuria, follow renal fnctn, UA, & cytology x 3 yrs

Re-evaluate if gross hematuria, irritative voiding sx, abnormal cytology

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