Introduction

Learning objectives

Structure the initial evaluation of a patient with hematuria.
Distinguish scheduled urologic referral from urgent referral.
Understand that painless gross hematuria in an adult must always be investigated.

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Video lesson

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Video pending upload (embedded YouTube)

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Summary

Hematuria can be gross —visible to the patient— or microscopic, detected on urinalysis.

Initial evaluation

Ask about:

presence of clots;
pain;
fever;
urinary symptoms;
history of stone disease;
smoking;
anticoagulation;
trauma;
history of urologic tumors.

Initial tests may include:

urinalysis;
urine culture if infection is suspected;
complete blood count depending on context;
renal function;
imaging studies according to risk and presentation.

When to refer?

Urologic referral:

gross hematuria without a clearly benign cause;
persistent microhematuria requiring evaluation according to risk factors;
risk factors for urologic neoplasia;
abnormal findings on imaging studies.

⚠️ Urgent referral

heavy hematuria with clots;
urinary retention due to clots;
bleeding with hemodynamic compromise;
significant anemia or clinical deterioration.

Key concept

Painless gross hematuria in an adult must be investigated. It should not be automatically attributed to anticoagulants, infection, or the prostate without an adequate evaluation.

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PDF

⬇ Download lesson summary

Downloadable PDF pending upload.

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Practical algorithm

🔴 Urgent referral / emergency

Sudden testicular pain → rule out torsion.
Fever/sepsis + obstructed urinary tract → urgent urinary drainage.
Acute urinary retention → bladder decompression; urgent referral if it cannot be resolved or if complications are present.
Hematuria + clot retention → urgent assessment and management.
Trauma + suspected urethral injury → avoid repeated blind catheterization attempts.

🟠 Priority referral

Solid testicular mass → rule out tumor.
Suspicious renal mass → characterization and urologic evaluation.
Gross hematuria → investigate the cause.
Persistently elevated PSA/suspicious DRE → prostate cancer risk assessment.

🟢 Scheduled referral depending on context

Recurrent UTI → look for a predisposing cause.
Erectile dysfunction → refer if complex, refractory, or with associated pathology.
Urinary incontinence → refer if complex, if warning signs are present, or if initial management fails.

The primary care physician does not need to resolve all urologic pathology. They must know how to perform an initial evaluation, recognize warning signs and, above all, distinguish which patient can wait from the one in whom a delay may compromise an organ, renal function, or even life.

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Clinical case

Content pending upload Progressive clinical case focused on decision-making.

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Self-assessment

Questions pending upload 5–10 multiple-choice questions on this lesson.

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References

Links pending upload References to PubMed, DOI, scientific society guidelines and journals.

Hematuria