Version July 2025
CT: computed tomography; hpf: high-power field; RBC: red blood cell; WBC: white blood cell.
* Gross hematuria is suspected when red or brown urine is present. However, red to brown urine can be seen in a variety of settings other than urinary tract bleeding, such as the use of certain medications (eg, rifampin, phenytoin, hydroxycobalamin, phenazopyridine, senna), consumption of food dyes, ingestion of certain foods (eg, beets, rhubarb), and acute intermittent porphyria.
¶ For more details regarding the management of the patient with acute urinary obstruction/retention from gross hematuria and blood clots, refer to UpToDate content on the management of acute gross hematuria in adults.
Δ In nonpregnant patients who cannot undergo CT urography, magnetic resonance urography (MRU) or noncontrast imaging plus retrograde pyelogram is an alternative option. In pregnant patients, kidney and bladder ultrasound is the preferred imaging modality rather than CT urography, largely to rule out ureteral obstruction or urolithiasis; further evaluation with CT urography should be deferred until after delivery.
◊ Hematuria as a symptom of malignancy is exceedingly rare in pregnant patients. In pregnant patients with hematuria, cystoscopy should generally be deferred, if possible, until after delivery. For those at higher risk of malignancy (eg, older age, past or current smoking history), cystoscopy can be considered during pregnancy based on shared decision making.
§ The evaluation for suspected nephrolithiasis generally involves an imaging study, typically noncontrast CT or ultrasound with or without abdominal radiography. Refer to UpToDate content on the evaluation of suspected nephrolithiasis for more details.
¥ The identification of RBC casts and dysmorphic RBCs by urine microscopy requires an experienced examiner (eg, nephrologist). Many clinical laboratories employ automated urine microscopic analyzers to identify cells and particles in urine; these platforms have not been shown to be as reliable as trained clinicians to distinguish RBC morphology. Clinicians should not rely upon the results of automated urine microscopy to identify signs of glomerular bleeding. If an experienced examiner is not available, referral to a nephrologist is reasonable while urologic sources of bleeding are also considered.
‡ If proteinuria is present (ie, 1+ or greater) on urine dipstick, it should be quantified with either a spot urine protein-to-creatinine ratio (UPCR) or urine albumin-to-creatinine ratio (UACR). Refer to UpToDate content on assessment of urinary protein excretion in adults for more information.