SUMMARY:

Hematuria accounts for approximately 20% of all Urology referrals. It is typically characterized as either gross (visible blood in urine) or microhematuria (RBCs on UA). Hematuria can be linked to a variety of etiologies, including infection, calculi, BPH, and—most importantly—malignancy. Studies have shown vastly different rates of genitourinary (GU) malignancy in patients with hematuria (<1% to 10%). While patients with gross hematuria generally undergo cystoscopy to rule out cancer, the evaluation and management of microhematuria is more nuanced. An updated 2025 AUA/ Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) guideline refines the risk stratification approach emphasizing GU malignancy risk to help guide diagnostic evaluation and includes recommendations regarding use of urinary tumor markers.

Diagnosis

• Definition
  • ≥3 RBCs/HPF on UA
  • Not diagnosed by urine dipstick alone

Evaluation

• H&P to identify possible sources
  • e.g. UTI, medical renal disease, gynecologic, malignancy
  • Urine cytology not recommended as part of initial evaluation
• Workup does not vary for patients on antiplatelets or anticoagulation
• If gynecologic or non-malignant GU source identified, treat accordingly and repeat UA upon resolution
  • If microhematuria persists or no etiology identified, perform risk-based evaluation
• If UTI is underying etiology
  • Obtain urinalusis is microsocpic evaluation after treatment to ensure resolution
• Refer to nephrologist if renal disease identified (e.g. cellular casts, proteinuria, elevated creatinine, or hypertension)
  • Risk based evaluation should still be done
• Categorize patient based on risk for GU malignancy to guide further workup

KEY POINTS:

Risk Stratification

Risk Factors used to establish risk level

• Irritation with voiding
• Cyclophosphamide/ifosfamide chemotherapy
• Family history of GU cancer or Lynch Syndrome
• Industrial exposure to benzenes/aromatic amines(e.g., rubber, petrochemicals, dyes)
• Chronic indwelling foreign body in GU tract

Low/negligible-risk: Must Meet All of the Following Criteria

• Women < 60 years | Men < 40 years
• Smoking history: Non-smoker or <10 pack-years
• UA: 3 to 10 RBCs/HPF
• No additional risk factors for GU cancer

Intermediate-risk: Must meet ≥1 of the following criteria

• Women ≥ 60 years  | Men 40 to 59 years
• Smoking history: 10 to 30 pack-years
• UA: 11 to 25 RBCs/HPF or previously low-risk with no diagnostic workup and 3 to 25 RBCs/HPF)
• ≥1 additional risk factor for GU cancer (see above)

High-Risk: Must Meet ≥1 of the Following Criteria

• Women and men ≥ 60 years
• Smoking history: > 30 pack-years
• UA: > 25 RBCs/HPF or history of gross hematuria
• ≥1 GU risk factor + any high-risk feature

Management

• Low/negligible-risk: Choice of option based on shared decision-making
  • Repeat UA within 6 months 
  • Immediate cystoscopy and renal ultrasound not recommended
• Intermediate-risk
  • Cystoscopy and renal ultrasound
  • After counseling, patients may instead opt for urine cytology or validated urine-based tumor markers to decide need for cystoscopy | Imagine still recommended
  • Patients who decline cystoscopy, imaging and markers
    • Revaluate at 12 months with urinalysis and if hematuria persistent, recommend cystoscopy
• High-risk
  • Cystoscopy and upper tract imaging
    • CT urography
    • MRI urography if CT urography contraindicated
    • Retrograde pyelography and non-contrast axial imaging or renal ultrasound if MRI urography also contraindicated

Note: Upper tract imaging should be performed in the setting of family history of renal cell carcinoma, known genetic renal tumor syndrome or personal history/suspicion for Lynch syndrome

Urinary Markers

• Do not routinely order urine cytology or urine-based tumor markers
  • In initial evaluation of low/negligible- or high-risk patients with microhematuria
  • As adjunctive tests in the setting of a normal cystoscopy
• Obtain urine cytology for
  • High-risk patients with equivocal findings on cystosocpy or
  • Persistent microhematuria and irritative voiding symptoms or
  • Risk factors for carcinoma in situ after a negative workup

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Learn More – Primary Sources

Microhematuria: AUA/SUFU Guideline