In adults with gross painless hematuria, what is the recommended initial evaluation?

• A. Urinalysis only
• B. CT angiography
• C. Urinalysis followed by cystoscopy and CT urography to evaluate for urothelial cancer
• D. Renal biopsy

Answer: (C)

In adults with gross painless hematuria, the goal is to evaluate for urothelial cancer throughout the urinary tract. Start with urinalysis to confirm blood and look for infection or stones. To directly assess the bladder for tumors and obtain biopsies if needed, perform cystoscopy. To evaluate the upper tract—the kidneys and ureters—for lesions such as tumors or stones, use CT urography. This combination provides both direct visualization of the bladder and comprehensive imaging of the upper tract, which is essential because painless hematuria can originate anywhere along the urinary tract. CT angiography isn’t the first-line test for this presentation, and renal biopsy isn’t indicated unless glomerular disease is suspected.