Asymptomatic microscopic hematuria

• Def.:
o Presence of three or more red blood cells per high-power field visible in a
properly collected urine specimen without evidence of infection
o According to the AUA, the presence of three or more red blood cells on a single,
properly collected, noncontaminated urinalysis without evidence of infection is
considered clinically significant microscopic hematuria
o Positive dipstick: need FU by U/A at least 3 times before considered negative
• The most common causes:
o Unknown (48-68%)
o Urinary tract infection: should resolve after appropriate antibiotic treatment;
persistence of hematuria warrants a diagnostic workup
o Benign prostatic hyperplasia
o Urinary calculi
o Urinary tract malignancy (5%). (but 30% to 40% in patients with gross hematuria)
• The risk of urologic malignancy:
o Men
o Persons older than 35 years
o Smoking
o Pelvic irradiation
o Chronic UTI
o Exposure to chemical or dyes
o Analgesics abuse
o Degree of hematuria
o Persistence of hematuria
o Irritative lower UT Sx
• Clinical evaluation:
o recommended for individuals with three or more red blood cells per high-power
field in a properly collected urine specimen in the absence of infection
o Clinicians should perform the same evaluation of patients with MH who are
taking antiplatelet agents or anticoagulants (regardless of the type or level of
therapy) as patients not on these agents
• Clinical assessment includes:
o Detailed Hx of all possible medical and surgical causes and risk factors for
malignancies
o Physical exam, including:
▪ BP check
▪ Signs of medical renal disease
▪ Pelvic exam for women: urethral masses, diverticula, atrophic vaginitis, or
a uterine source of bleeding
▪ PR exam for men: to evaluate the size and presence of nodularity in the
prostate
• Risk stratification:
• Low risk (patient meets all criteria)
o Women age <50 years
o Men age <40 years
o Never smoker or <10 pack years
o 3-10 RBC/HPF on a single urinalysis
o No risk factors for urothelial cancer
• Intermediate (patient meets any one of these criteria)
o Women age 50-59 years
o Men age 40-59 years
o Smoking: 10-30 pack years
o 11-25 RBC/HPF on a single urinalysis
o Low-risk patient with no prior evaluation and 3-10 RBC/HPF on repeat urinalysis
o Additional risk factors for urothelial cancer
• High (patient meets any one of these criteria)
o Women or Men age ≥60 years
o Smoking: >30 pack years
o >25 RBC/HPF on a single urinalysis
o History of gross hematuria
• Referral:
o Dysmorphic red blood cells, cellular casts, proteinuria, elevated creatinine levels,
or hypertension in the presence of microscopic hematuria
o High risk of malignancy
• Imaging:
o The upper urinary tract is best evaluated with multiphasic CT urography, to
identifies hydronephrosis, urinary calculi, and renal and ureteral lesions.
o The lower urinary tract is best evaluated with cystoscopy for urethral stricture
disease, BPH, and bladder masses.
o Voided urine cytology: no longer recommended routinely unless malignancy risk
• Clinical approach of incidental finding of microscopic hematuria:
o Assess for benign causes (UTI / Vigorous exercise / menstruation / recent
urological procedure / infection of viral illness)
o Repeat U/A after 6 weeks from treating the contributing factor:
▪ If negative; no further work up
▪ If positive: assess for medical renal disease (e.g. Immunoglobulin A
nephropathy, Alport syndrome, benign familial hematuria) by looking for
dysmorphic red blood cells, cellular casts, proteinuria, elevated creatinine
levels:
• If positive: nephro referral
• If negative: categorize patient according to risk of malignancy:
o Low risk: engage patients in shared decision-making to
decide between repeating UA within six months or
proceeding with cystoscopy and renal ultrasound
 o If positive after 6/12, consider them as intermediate risk
o Intermediate risk: perform cystoscopy and U/S
o High risk: multiphasic CT urography. If have allergy to
contrast or renal impairment: by MRI or Noncontrast CT or
U/S
o In patients a family history of renal cell carcinoma (RCC)
or a known genetic renal tumor syndrome, should perform
upper tract imaging regardless of risk category
• Clinicians should not use urine cytology or urine-based tumor
markers in the initial evaluation of patients with MH
• If appropriate workup does not reveal nephrologic or urologic disease, then annual
urinalysis should be performed for at least two years after initial referral.
• If these two urinalyses do not show persistent hematuria, the risk of future malignancy is
less than 1%
• Screening for bladder cancer:
o There is insufficient evidence to recommend screening urinalysis for the detection
of bladder cancer in the absence of clinical indicators.

Source:
• Assessment of Asymptomatic Microscopic Hematuria in Adults - American Family Physician
(aafp.org)
• Adult Urology | Journal of Urology (auajournals.org)