In evaluating gross hematuria that appears benign, what is the recommended next step?

• A. Observation only
• B. Cystoscopy to evaluate for bladder cancer
• C. Renal biopsy
• D. Urine culture

Answer: (B)

Painless gross hematuria can be an early sign of bladder cancer, so even when the appearance seems benign you still need a thorough evaluation rather than just watching and waiting. Cystoscopy allows direct visualization of the bladder mucosa and ureteral openings, making it the most informative test to detect urothelial tumors and to take targeted biopsies if any lesion is found. Early detection of bladder cancer improves outcomes, and cystoscopy is the standard next step in adults with new gross hematuria.

Watching without investigation risks missing a malignancy. A renal biopsy is reserved for suspected intrinsic kidney disease, not for evaluating hematuria from the bladder. A urine culture checks for infection but doesn’t assess cancer risk, so it wouldn’t address the concern if cancer is the underlying cause.