UPDATE
EVALUATION OF ASYMPTOMATIC MICROSCOPIC
HEMATURIA IN ADULTS: THE AMERICAN UROLOGICAL
ASSOCIATION BEST PRACTICE POLICY—PART I:
DEFINITION, DETECTION, PREVALENCE, AND ETIOLOGY
GARY D. GROSSFELD, MARK S. LITWIN, J. STUART WOLF, JR, HEDVIG HRICAK,
CATHRYN L. SHULER, DAVID C. AGERTER, AND PETER R. CARROLL
H ematuria can originate from any site along the
urinary tract and, whether gross or micro-
scopic, may be a sign of serious underlying disease,
including malignancy. Gross hematuria usually
causes alarm with the patient, prompting a rush to
seek medical attention. Most physicians agree that
the presence of gross hematuria warrants a thor-
ough diagnostic evaluation to determine its cause,1
and therefore there is little controversy in the liter-
ature with respect to the evaluation of gross hema-
turia.
In contrast, published reports regarding the di-
agnosis, etiology, and evaluation of asymptomatic
microscopic hematuria are rife with controversy.
Microscopic hematuria is an incidental finding of-
ten discovered as part of a routine examination.
Whether physicians should routinely screen for
hematuria in asymptomatic patients is a point at
issue. Other issues include what amount of blood
in the urine constitutes significant hematuria, what
proportion of patients with asymptomatic micro-
scopic hematuria are likely to have clinically sig-
nificant disease, and whether a full urologic evalu-
ation is justified. To address these issues, the
From the Department of Urology, University of California School
of Medicine, San Francisco and Program in Urologic Oncology,
University of California San Francisco/Mount Zion Comprehen-
sive Care Center, San Francisco, California; Departments of
Urology and Health Services, University of California, Los Ange-
les, Schools of Medicine and Public Health, Los Angeles, Califor-
nia; Department of Surgery (Urology), University of Michigan
School of Medicine, Ann Arbor, Michigan; Memorial Sloan-Ket-
tering Cancer Center, New York, New York; Department of Med-
icine, Division of Nephrology, Oregon Health Sciences Univer-
sity, Portland, Oregon; and Department of Family Medicine,
Mayo Medical School and Mayo Clinic Rochester, Rochester,
Minnesota
Reprint requests: Gary Grossfeld, M.D., c/o Carol Schwartz,
M.P.H., R.D., Guidelines Manager, American Urological Associ-
ation, 1120 North Charles Street, Baltimore, MD 21201-5559
Submitted: October 5, 2000, accepted (with revisions): Decem-
ber 12, 2000
© 2001, ELSEVIER SCIENCE INC.
ALL RIGHTS RESERVED
American Urological Association convened the
Best Practice Policy Panel on Asymptomatic Micro-
scopic Hematuria and charged this panel with for-
mulating best practice recommendations for the
detection and evaluation of asymptomatic micro-
hematuria.
The panel formulated its policy statements and
recommendations by consensus, on the basis of a
review of published reports and the panel mem-
bers’ own expert opinions. This best practice pol-
icy document is meant to offer guidance to all
health care providers whose adult patients may
have asymptomatic microscopic hematuria. The
panel’s multispecialty membership included a fam-
ily physician, a nephrologist, and a radiologist, as
well as urologists.
After the panel reached an initial consensus, the
manuscript was circulated to 85 peer reviewers
representing the following medical specialties:
family practice, internal medicine, radiology, ne-
phrology, and urology. Comments were received
from 55 peer reviewers, and the panel made nu-
merous changes to the document to incorporate
the suggested concepts the panel considered to be
warranted.
DETECTION AND DEFINITION
OF ASYMPTOMATIC
MICROSCOPIC HEMATURIA
Red blood cells (RBCs) in the urine are not al-
ways a sign of underlying disease. Previous studies
have reported that between 9% and 18% of appar-
ently normal individuals have some degree of he-
maturia.2–7 However, the actual number of eryth-
rocytes that can be excreted under “normal”
conditions is difficult to determine. Different
methods used by different investigators to deter-
mine the presence of hematuria, different defini-
tions of the “normal” population among studies,
the inability to control for activities before urine
UROLOGY 57: 599 – 603, 2001 • 0090-4295/01/$20.00
PII S0090-4295(01)00919-0 599
 TABLE I. Reported causes of asymptomatic microscopic hematuria
Significant, Requiring Significant, Requiring
Life-Threatening Treatment Observation Insignificant
Bladder cancer Renal calculus Radiation cystitis Urethrotrigonitis
Renal cell carcinoma Vesicoureteral reflux Bladder diverticulum Renal cyst
Prostate cancer Bacterial cystitis Atrophic kidney Duplicated collecting system
Ureteral transitional cell Bladder calculus Bladder neck contracture Prostatic calculus
carcinoma Ureteropelvic junction Interstitial cystitis Bladder neck polyps
Renal transitional cell obstruction Asymptomatic BPH Urethral polyps
carcinoma Renal parenchymal Papillary necrosis Bladder
Metastatic carcinoma disease Renal arteriovenous varices/telangiectasia
Urethral cancer Symptomatic BPH fistula Scarred kidney
Penile cancer Urethral Renal contusion Trabeculated bladder
Renal lymphoma stricture/meatal Polycystic kidney Urethral caruncle
Abdominal aortic aneurysm stenosis Prostatitis Pseudomembranous
Bladder papilloma Cystocele trigonitis
Mycobacterial cystitis Neurogenic bladder Urethritis
Pyelonephritis Cystitis cystica/glandularis Pelvic kidney
Hydronephrosis Ureterocele Caliceal diverticulum
Ureteral calculus Eosinophilic cystitis Exercise hematuria
Renal artery stenosis Phimosis
Renal parenchymal
disease
Renal vein thrombosis
KEY: BPH ⫽ benign prostatic hyperplasia.

collection that may transiently induce hematuria
(such as exercise, trauma, and/or sexual activity),
and inadequate follow-up of the normal popula-
tion under study are all factors that contribute to
this uncertainty.8,9
The degree of hematuria can be measured quan-
titatively by determining the number of RBCs per
milliliter of urine excreted (the so-called chamber
count), by direct examination of the centrifuged
urinary sediment (sediment count), or indirectly
by dipstick examination of the urine. The chamber
count has been suggested to have greater precision
and sensitivity than the sediment count, but the
sediment count is easier to perform, less time-con-
suming, and more cost-effective than the chamber
count.10 Consequently, most investigators prefer
to examine the urinary sediment when evaluating a
patient for the presence of microscopic hematuria.
The chamber count and sediment count have been
shown to correlate with acceptable sensitivity.10
However, the sediment count is only a semiquan-
titative method of determining the degree of hema-
turia, and thus not entirely interchangeable with
the chamber count.8,9
The simplest way to detect microscopic hematu-
ria is with a urinary dipstick. Hemoglobin, either
free in the urine or within urinary RBCs, catalyzes
an oxidation reaction between substances on the
dipstick, resulting in a color change that indicates
the presence of hematuria.9 Urinary dipsticks have
been very useful in the detection of asymptomatic
microscopic hematuria, with a sensitivity of 91% to
100%. However, the specificity of urinary dipsticks
is limited, ranging from 65% to 99% for 2 to 5 RBCs
per high-power microscopic field (HPF).8,10 –12
False-positive results on dipstick analysis may be
due to myoglobin or free hemoglobin in the urine,
as well as oxidizing contaminants in the urine such
as Betadine (povidone-iodine).9 It should be noted
that in patients with a low urine specific gravity
(less than 1.007), most urinary RBCs will lyse and,
in this circumstance, urinary dipsticks may be a
more accurate reflection of hematuria than micro-
scopic examination of the urinary sediment.13
It is recommended that urinalysis to detect mi-
croscopic hematuria be performed on a freshly
voided, clean-catch, midstream urine specimen.
The initial determination regarding the presence of
microscopic hematuria should be based on micro-
scopic examination of the urinary sediment.
The standard technique involves centrifugation
of 10 mL of urine for 5 minutes at approximately
2000 rpm.14 After centrifugation, the supernatant
should be discarded and the sediment resuspended
in 0.5 to 1.0 mL of the remaining urine. A drop of
resuspended urine should be examined under the
high-power microscope objective. If urine contam-
ination by the skin or vaginal mucosa is evident,
such as the presence of squamous epithelial cells,
the examination should be repeated on a new spec-
imen and consideration given to obtaining a cath-
eterized specimen.
The most commonly accepted upper limit of nor-
mal for urinary RBCs, based on examination of the

600 UROLOGY 57 (4), 2001

 TABLE II. Incidence of highly or moderately significant disease in patients with hematuria who
underwent full urologic evaluation
Patients
with Highly
or Patients
Moderately with
Significant Urologic
Patients Disease Malignancy
Reference (n) Population Evaluated (%) (%)
Bard22 177 Women ⱖ20 yr 3.4 0
Britton et al.17 61 Men 60–85 yr 56 8.2
Britton et al.18 319 Men ⬎60 yr NA 8.3
Carson et al.23 200 All patients referred for urologic 52 13
evaluation
Davides et al.24 150 All patients referred for urologic 49 8.7
evaluation
Fracchia et al.25 100 All patients referred for urologic 13 5
evaluation
Greene et al.26 500 All patients referred for urologic 9.4 2.2
evaluation
Golin and Howard27 246 All patients referred for urologic 22 10
evaluation
Jones et al.28 100 Men ⬍40 yr 18 0
Mariani et al.5 1000 All patients referred for urologic 32 8.6
evaluation
Messing et al.12 19 Men ⱖ50 yr 53 26
Messing et al.16 31 Men ⱖ50 yr 48 25.8
Messing et al.19 192 Men ⱖ50 yr 33 8.3
Murakami et al.29* 1034 All patients with microhematuria 22 2.3
on annual health examination
Ritchie et al.20* 76 Patients with microhematuria 17 2.6
on health screening who
underwent subsequent
evaluation
Thompson21* 85 Men ⱖ40 yr 22 1.2
* Patients in these three studies were not from selected populations. Asymptomatic microhematuria was an incidental discovery during routine physical examination. Patients
in all the other studies were either urologic referral patients or from selected screening populations.
KEY: NA ⫽ not available.

urine sediment, is 2 to 3 RBCs/HPF.8,15 Although maturia is 3 or more RBCs/HPF on microscopic

many investigators have used this definition to de-
fine the presence of microscopic hematuria, other
investigators have considered more than 5 RBCs/
HPF to be evidence of significant microscopic he-
maturia. Still others have considered any degree of
hematuria to be abnormal.
It has been documented that hematuria associ-
ated with significant urologic disease may be inter-
mittent in nature.16 Thus, a negative repeated uri-
nalysis in someone who has previously had a
positive test may not be sufficient to exclude the
presence of significant disease. To account for the
intermittent nature of hematuria due to urologic
malignancy, Mariani and colleagues5 proposed
that patients with more than 3 RBCs/HPF on two of
three properly collected and examined urine spec-
imens should be considered to have microhematu-
ria and thus evaluated appropriately.
The recommended definition of microscopic he-
evaluation of the urinary sediment from two of
three properly collected urinalysis specimens. As
there is no safe lower limit for hematuria, risk fac-
tors for significant disease should be taken into
consideration before deciding to defer an evalua-
tion in patients with 1 or 2 RBCs/HPF. High-risk
patients (especially those with a history of smoking
or chemical exposure) should be considered for a
full urologic evaluation after one properly per-
formed urinalysis documenting the presence of at
least 3 RBCs/HPF.
Given the limited specificity of urinary dipsticks
and the risk and expense of a hematuria evaluation,
an initial finding of microscopic hematuria on uri-
nary dipstick should be confirmed by microscopic
evaluation of the urinary sediment. A positive dip-
stick examination that is not confirmed with exam-
ination of the urinary sediment should not lead to
a complete urologic evaluation.

UROLOGY 57 (4), 2001 601

 PREVALENCE OF ASYMPTOMATIC
MICROSCOPIC HEMATURIA
The prevalence of asymptomatic microscopic he-
maturia has been estimated in both unselected,
population-based studies and in screening or refer-
ral-based studies examining selected patient popu-
lations. Woolhandler and colleagues11 reviewed
five population-based cohort studies with patient
populations ranging from 1000 to 95,200. The es-
timated prevalence of asymptomatic microscopic
hematuria varied in these studies from 0.19% to
16.1%. Such wide variations reflect the differences
in the age and sex of populations screened, the
amount of follow-up, and the number of screening
studies per patient.
The prevalence of microscopic hematuria has
also been determined in patient populations se-
lected for their participation in health care screen-
ing programs and is reported to range from 2.5% to
21.1%.12,16 –21 In two studies of men older than 60
years who underwent voluntary screening for blad-
der cancer, Britton and colleagues17,18 reported
prevalences of 13% and 20.1%. In three studies by
Messing and colleagues,12,16,19 high-risk, asymp-
tomatic men older than 50 years were screened for
bladder cancer using urinary dipsticks to detect
occult bleeding. Microscopic hematuria was
present in 10% to 21% of these subjects.
There is no general consensus regarding when to
test for microscopic hematuria in asymptomatic
adults in a primary care setting. Although bladder
cancer is the most commonly detected malignancy
in patients with microscopic hematuria, no major
organization currently recommends screening for
bladder cancer in asymptomatic adults. The Amer-
ican Cancer Society has not issued any specific
guidelines on screening for bladder cancer, and the
U.S. Preventive Services Task Force (1996) and the
Canadian Task Force on the Periodic Health Ex-
amination both recommend against routinely
screening asymptomatic patients for hematuria to
identify those with urologic malignancies. The Ca-
nadian Task Force has also concluded that the ev-
idence is insufficient to recommend either for or
against such screening even in specific high-risk
patients.
As no agreement has been reached on when to
test for asymptomatic microscopic hematuria in
the primary care setting, the physician should be
guided by the results of the patient’s history and
physical examination in deciding whether testing
is appropriate. Risk factors for significant underly-
ing disease include age older than 40 years; tobacco
use; analgesic abuse (eg, phenacetin); laxatives
that may cause renal disease; history of pelvic irra-
diation; cyclophosphamide; and exposure to occu-
602
pational toxins such as dyes, benzenes, and aro-
matic amines.
ETIOLOGY
The proportion of patients with asymptomatic
microscopic hematuria who are subsequently diag-
nosed with significant urologic disease reflects
both the patient population under investigation
and the extent of the urologic evaluation that is
performed. Most studies in which patients with
asymptomatic microscopic hematuria have under-
gone full urologic evaluation have included refer-
ral-based populations. A full evaluation in these
studies often included a repeated urinalysis, urine
culture, upper urinary tract imaging, cystoscopy,
and urinary cytology. Of the patients who undergo
a full urologic evaluation, a cause for asymptom-
atic microscopic hematuria can be determined in
32% to 100%.5,12,16 –29 Finding the cause is depen-
dent on both the population studied and the will-
ingness of the investigator to assign “insignificant”
findings as the cause of the hematuria.
Causes of asymptomatic microscopic hematuria
range from minor, incidental findings that do not
require treatment to highly significant lesions that
immediately threaten the patient’s life. The tradi-
tional classification of such causes was based on
three categories as proposed by Greene and col-
leagues.26 Highly significant disease posed a clear
threat to the patient’s life and/or required major
surgery. Moderately significant disease was consid-
ered to be remotely life-threatening and usually
required some form of medical treatment. Insignif-
icant disease did not require treatment. More re-
cently, Mariani and colleagues5 revised this classi-
fication into four categories (Table I). Although
these categories are inherently subjective, a num-
ber of investigators continue to find them useful.
Table II summarizes the incidence of moderately
and highly significant urologic disease in patients
with asymptomatic microscopic hematuria who
underwent a full urologic evaluation. The percent-
age differences from study to study mainly reflect
differences in the patient populations under inves-
tigation.
Patients with asymptomatic microscopic hema-
turia who are at risk of urologic disease or primary
renal disease should undergo an appropriate eval-
uation because (a) such an evaluation will often
determine the cause of the hematuria and (b) a
substantial number of patients will be found to
have moderately or highly significant disease (in-
cluding malignancy). For patients at low risk of
disease, some components of the evaluation may
be deferred (see Part II of the Best Practice Policy in
this issue of UROLOGY).
UROLOGY 57 (4), 2001
 ACKNOWLEDGMENT. To Lisa Cowen, Ph.D. and Carol
Schwartz, M.P.H.
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