What is the typical initial evaluation for painless hematuria?

• A. Urinalysis to confirm hematuria, followed by imaging (CT urogram or ultrasound) and cystoscopy if indicated based on findings
• B. Urinalysis only
• C. CT urogram alone without urinalysis
• D. Ultrasound only

Answer: (A)

When painless hematuria is detected, the best approach starts with confirming the finding and characterizing it, then evaluating the urinary tract step by step. A urinalysis with microscopic examination confirms that red blood cells are actually present in the urine and helps rule out false positives or nonhematuria causes, while also noting any associated signs like infection or proteinuria. After confirming hematuria, imaging of the kidneys, ureters, and bladder is pursued to identify upper-tract sources such as stones or urothelial tumors, with CT urography as a comprehensive option (or ultrasound when CT is not appropriate). If imaging or clinical features point to bladder involvement, or if there is persistent microscopic hematuria despite a negative initial workup, cystoscopy is performed to directly visualize the bladder mucosa and ureteral openings and to obtain biopsies if needed. This staged strategy—urinalysis first, then imaging, then cystoscopy when indicated—best balances noninvasiveness with thorough evaluation of potential causes.