An otherwise healthy 57-year-old man with a 20 pack-year history of smoking presents with a...

This patient has gross painless hematuria (reddish-brown urine) and is over age 50 with a smoking history—major risk factors for urothelial carcinoma (bladder cancer) . MCCQE objectives emphasize that any episode of gross painless hematuria in adults warrants urgent evaluation for malignancy , regardless of the number of red blood cells seen on urinalysis. Even microscopic hematuria in higher-risk individuals requires thorough workup.

The most important next step is cystoscopy , which directly visualizes the bladder and lower urinary tract to identify tumors, the most common cause of painless hematuria in this demographic. Imaging (e.g., CT urography) is also part of a complete evaluation, but cystoscopy is essential for diagnosing bladder lesions. Intravenous pyelography is outdated and less sensitive. Ultrasonography may detect masses but does not replace cystoscopy. Reassurance or delayed repeat urinalysis would risk missing a malignancy.

Therefore, immediate urologic referral for cystoscopic evaluation is the appropriate next step.