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Assessing hematuria risks

Epidemiology

• 3+ RBCs on microscopic UA warrant assessment and potential hematuria workup
• 1 urinalysis with RBCs is all that is required for a hematuria workup
• 6.5% healthy patients have microscopic hematuria on screening tests
• 2.5% (0.7-4.3%) patients with asymptomatic microscopic hematuria have underlying malignant cause
• 33-67% patient do not have diagnosible cause of hematuria (positional, physical activity, recent intercourse)

Risk factors

• Smoking: increases risk of bladder cancer
• Radiation: XRT cystitis, secondary malignancy, fistula
• Chemotherapy: cyclophosphamide can lead to hemorrhagic cystitis
• UTI: hematuria may be a presenting symptom
• Chronic catheter: irritation or development of SCC bladder cancer
• Chemical exposure: benzenes, aromatic amines increases risk of bladder cancer
• Hx stones, BPH, trauma: benign causes of hematuria
• Dysuria: in absence of UTI, may be presenting symptom of carcinoma in situ
• Hx cancer: either GU-specific or syndromic (Lynch, VHL)

Hematuria workup

Risk Groups

Risk	Needs all criteria?	Age	Smoking (packyears)	# RBC (UA x1)	Urothelial cancer risk factors*	Prior hematuria	Probability malignant cause	Recommendations
Low	Yes	Women < 50 Men < 40	< 10	3-10	None	No	0.2-0.5%	Repeat UA in 6mo, OR... Cysto + renal US
Intermediate	No	Women 50-59 Men 40-59	10-30	11-25	1+	Persistent 3-10 RBC	1.3-1.6%	Cysto + renal US
High	No	60+	> 30	> 25	-	Gross	10.8-11.1%	Cysto + CTU

^*Risk factors include increased age, male, prior smoking, irritative voiding symptoms, prior pelvic radiation, prior cyclophosphamide, history urothelial cancer or Lynch syndrome, prior occupational exposures, and chronic indwelling foreign body

Considerations

• Hematuria in setting of UTI does not warrant workup, perform workup if hematuria persists after treatment (wait 3wks-3mo)
• Patients on anticoagulation should undergo same workup
• If benign cause identified and treatment, discuss with patient whether further workup is warranted
• Perform full workup even if nephrologic cause suspected (increased risk for GU cancers in setting of decreased renal function)
• Patients should undergo thorough upper tract imaging if family history RCC or genetic syndrome

Workup components

• Upper tract imaging: CTU, MRU, renal US + retrograde pyelograms
• Renal US: less sensitive for upper tract urothelial cancer but very sensitive for renal neoplasms, but due to rarity the costs outweigh the benefits
• Cystoscopy: perform without enhancement (blue light), preferable as screening test
• If persistent/worsening hematuria after renal US, obtain further imaging
• Cytology: obtain only if persistent microhematuria, irritative voiding symptoms, or risk for CiS
• Labs: consider BMP if nephrologic concerns, PSA if male and > 40yo, can also consider CBC and coags

Follow-up

• Low risk (no workup) and negative repeat UA at 12mo no further workup
• Int/high risk and negative initial workup: repeat UA in 12mo
• Repeat UA negative: no further workup
• Persistent microhematuria: discuss need for further workup immediately or in 3-5yrs
• Worsening hematuria: obtain further workup