INTRODUCTION: To explore further the association of baseline health and gender with small renal mass pathology as approximately 20% of those masses are benign and women are twice as likely as men to have benign pathology. MATERIALS AND METHODS: We conducted retrospective chart reviews of patients with renal masses ≤ 4 cm who underwent partial and radical nephrectomy from 1998 to 2012. Multivariable logistic regression analysis was performed to determine demographic and clinicopathologic factors associated with malignant pathology. RESULTS: In our cohort of 1726 patients, compared to patients with benign pathology, those with malignant pathology included a higher proportion of men (64.3% versus 42.7%, p < 0.01) and high American Society of Anesthesiologists class (43.8% versus 37.3%, p = 0.04), and had higher preoperative serum creatinine levels (1.1 mg/dL versus 1.0 mg/dL, p < 0.01) and larger tumors (2.5 cm versus 2.2 cm, p < 0.01). Gender-specific multivariable logistic regression analysis showed that in women factors associated with malignant pathology were high American Society of Anesthesiologists class (OR 1.57, 95% CI 1.07-2.32, p = 0.02) and tumor size (OR 1.46, 95% CI 1.19-1.79, p < 0.01). In men, factors associated with malignant pathology were tumor size (OR 1.33, 95% CI 1.06-1.67, p = 0.01) and age (OR 0.97, 95% CI 0.95-0.99, p < 0.01). CONCLUSIONS: Our results are consistent with prior reports, in which male gender and larger tumor size are significantly associated with malignant small renal masses. In addition, poor baseline health as represented by a high American Society of Anesthesiologists class is significantly associated with malignant pathology in women.