MKSAP Quiz: 1-week history of gross hematuria

MKSAP Answer and Critique

The correct answer is A. Cystoscopy. This content is available to ACP MKSAP subscribers in the Nephrology section. More information about ACP MKSAP is available online.

The most appropriate diagnostic test to perform next is cystoscopy (Option A). Hematuria, defined as an erythrocyte count ≥3/hpf in the urine sediment, may be microscopic (detected by urine microscopy) or macroscopic (grossly visible). A glomerular origin is suggested by concurrent proteinuria, presence of acanthocytes, increased serum creatinine level, decrease in estimated glomerular filtration rate, or systemic signs and symptoms (none of which are present in this patient). Macroscopic hematuria should prompt urology referral even if self-limited, with further evaluation of glomerular disease and malignancy as indicated. The American Urological Association (AUA) guidelines recommend stratifying patients with hematuria as having low, intermediate, or high risk for an underlying urothelial malignancy, with risk status dictating subsequent management. Patients at low risk include those with the following features:

• Women <50 years and men <40 years who have never smoked
• Erythrocyte count of 3 to 10/hpf noted only on a single urinalysis
• No additional risk factors for urothelial cancer

Patients at low risk should have a repeat urinalysis within 6 months and, if normal, require no additional evaluation.

Patients at high risk include those with any of the following features:

• >60 years
• >30-pack-year history of smoking
• Erythrocyte count >25/hpf
• Gross hematuria

Patients at high risk require cystoscopy and CT or magnetic resonance urography. Patients at intermediate risk include all others not included in either the low- or high-risk categories and require prompt kidney ultrasonography and cystoscopy. This patient has gross hematuria and several high-risk features that raise suspicion for bladder cancer, including age, lengthy smoking history, and numerous erythrocytes on urinalysis; he requires cystoscopy and imaging.

Kidney biopsy (Option B) would be helpful to determine the cause of glomerular disease or for further evaluation of a mass or lesion. In this patient, the initial evaluation should involve cystoscopy and imaging; kidney biopsy is not indicated for nonglomerular hematuria.

Patients at intermediate risk for urothelial malignancy require prompt kidney imaging, such as ultrasonography, and cystoscopy. Because this patient is stratified as high risk for an underlying urothelial malignancy, kidney ultrasonography (Option C) is not an appropriate test; he should instead undergo CT or magnetic resonance urography and cystoscopy.

The American College of Physicians and the AUA recommend against obtaining urine cytology (Option D) in the initial evaluation of hematuria because it does not improve detection of bladder cancer.

Key Points

• The American Urological Association guidelines recommend stratifying patients with hematuria as having low, intermediate, or high risk for an underlying urothelial malignancy, with risk status dictating subsequent management.
• Patients who are considered high risk for urothelial malignancy require cystoscopy and CT or magnetic resonance urography.