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 (MH) is more nuanced. The 2012 American Urological Association (AUA) guideline recommended cystoscopy and CT urogram for all patients >35 with MH. An updated 2020 AUA/ Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) guideline introduces a system of stratifying patients based on risk for GU malignancy to help guide diagnostic evaluation.

Diagnosis

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

Work-up of MH

• 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
• Refer to nephrologist if renal disease identified (e.g. cellular casts, proteinuria, elevated creatinine, or hypertension)
• Categorize patient based on risk for GU malignancy to guide further workup

KEY POINTS:

Risk Stratification

Low-risk: Must Meet All of the Following Criteria

• Women < 50 | Men < 40
• Smoking history: Non-smoker or <10 pack-years
• UA: 3 to 10 RBCs/HPF and no prior MH
• No additional risk factors for GU cancer, which include the following
  • Irritation with voiding | Cyclophosphamide/ifosfamide chemotherapy | Family history of GU cancer or Lynch Syndrome, industrial exposure to benzenes/aromatic amines (e.g. printers, painters, concrete workers, textile workers, plastics and metal workers) chronic indwelling foreign body in GU tract)

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

• Women 50 to 59 | Men 40 to 59
• 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
• Smoking history: > 30 pack-years
• UA: > 25 RBCs/HPF
• History of gross hematuria

Management

• Low-risk: Choice of option based on shared decision-making
  • Repeat UA within 6 months or
  • Cystoscopy and renal ultrasound
• Intermediate-risk
  • Cystoscopy and renal ultrasound
• High-risk
  • Cystoscopy and CT urogram

Note: For all risk categories: If negative workup, “consider” repeat UA within 12 months

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Learn More – Primary Sources

Microhematuria: AUA/SUFU Guideline