MCQs on Hematuria

Written by Dr. Daniel Fraser (MBBS, FRACP) – Physician

Question 1

A 62-year-old man presents to his GP after noticing blood in his urine this morning. He describes the urine as red in color but denies any pain, dysuria, or fever. He has a 40-pack-year smoking history and worked in a rubber factory for 30 years. He is not on any anticoagulants. Examination is unremarkable. Urinalysis confirms the presence of red blood cells, but no casts or proteinuria. His blood pressure is normal and kidney function is within normal range.

Which of the following is the most appropriate next step in management?

A) Start empirical antibiotics for presumed UTI
B) Reassure and schedule follow-up in 6 months
C) Arrange for cystoscopy and imaging of the urinary tract
D) Perform a renal biopsy
E) Initiate corticosteroids for presumed glomerulonephritis

Correct Answer: C) Arrange for cystoscopy and imaging of the urinary tract

Explanation:
This patient presents with painless visible hematuria, which is considered gross hematuria and must be evaluated thoroughly to exclude serious underlying pathology—particularly urothelial malignancy. His risk factors include age over 60, heavy smoking history, and occupational exposure to chemicals (aniline dyes), which strongly increase the risk of bladder cancer.

Initial work-up should include:

Cystoscopy to visualize the bladder and lower urinary tract
Imaging, typically CT urography, to evaluate the upper tract

Why the other options are incorrect:
A) Empirical antibiotics – Not appropriate without symptoms of infection or positive dipstick
B) Reassurance – Delay in investigation may miss an early cancer diagnosis
D) Renal biopsy – Indicated for glomerular causes (e.g., RBC casts, proteinuria, hypertension)
E) Corticosteroids – Not appropriate without evidence of glomerular disease

Question 2

A 28-year-old man presents with dark-colored urine that developed 2 days after a sore throat. He has no fever, dysuria, flank pain, or urinary frequency. His past medical history is unremarkable. On examination, his blood pressure is 138/86 mmHg and there is no peripheral edema. Urinalysis shows red blood cells and mild proteinuria. Serum creatinine is normal. A renal biopsy is later performed, revealing mesangial proliferation with IgA deposition on immunofluorescence.

Which of the following is the most likely diagnosis?

A) Post-streptococcal glomerulonephritis
B) IgA nephropathy
C) Alport syndrome
D) Thin basement membrane disease
E) Lupus nephritis

Correct Answer: B) IgA nephropathy

Explanation:
This patient presents with episodic gross hematuria occurring within a few days of an upper respiratory tract infection. This timing is characteristic of IgA nephropathy (Berger’s disease), the most common glomerulonephritis worldwide. The renal biopsy confirms the diagnosis with mesangial IgA deposition.

Key features of IgA nephropathy include:

Recurrent hematuria associated with mucosal infections
Normal renal function in early disease
Mild proteinuria
Diagnosis confirmed by renal biopsy

Why the other options are incorrect:
A) Post-streptococcal GN – Typically occurs 1–3 weeks after infection, not within days
C) Alport syndrome – Inherited condition; associated with hearing loss and ocular abnormalities
D) Thin basement membrane disease – Causes microscopic, not gross, hematuria; normal renal function
E) Lupus nephritis – Usually affects women; presents with systemic signs and positive ANA/anti-dsDNA

Question 3

A 35-year-old man presents to the Emergency Department with sudden onset of severe left flank pain that radiates to the groin. He appears restless and is unable to find a comfortable position. He denies fever or dysuria. His urine dipstick is positive for blood but no nitrites or leukocytes. A non-contrast CT scan of the abdomen reveals a 6 mm calculus in the left distal ureter.

Which of the following is the most likely cause of his hematuria?

A) Acute glomerulonephritis
B) Bladder cancer
C) Renal cell carcinoma
D) Urolithiasis
E) Urinary tract infection

Correct Answer: D) Urolithiasis

Explanation:
This patient’s classic presentation—sudden colicky flank pain radiating to the groin with microscopic hematuria and imaging showing a ureteric stone—is typical of urolithiasis. Stones can cause hematuria due to mucosal irritation and trauma along the urinary tract.

Key features include:

Severe, colicky flank pain
Restlessness, unable to find a position of relief
Hematuria (microscopic or gross)
Diagnosis confirmed with non-contrast CT KUB

Why the other options are incorrect:
A) Acute glomerulonephritis – Usually painless hematuria, with red cell casts and proteinuria
B) Bladder cancer – Typically causes painless gross hematuria, not acute pain
C) Renal cell carcinoma – May cause hematuria but rarely presents with colicky pain
E) Urinary tract infection – Often presents with dysuria, frequency, and leukocyturia

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4. Nephrology & Urology Module

4.1 Hematuria

4.2 Chronic Kidney Disease

4.3 Urinary Incontinence

4.4 Prostate

4.5 Renal Tumors

4.6 Other Renal Disorders

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