Microscopic hematuria algorithm, from AUA Guidelines
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
- Probability of subsequent cancer: less than 1% if negative initial workup, equivalent to general population risk for developing GU cancer
- 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
References
- AUA Core Curriculum
- Barocas, Daniel A., et al. "Microhematuria: AUA/SUFU Guideline." The Journal of urology 204.4 (2020): 778-786.
- Boorjian, et al. "Evaluation and management of hematuria." Campbell-Walsh Urology. 12th ed. Philadelphia, PA: Elsevier (2020): 247-259.
- Castle, E., C. Wolter, and M. Woods. "Evaluation of the Urologic Patient: Testing and Imaging." Campbell-Walsh Urology 12 (2020).
- Lee, Joo Yong, et al. "Hematuria grading scale: a new tool for gross hematuria." Urology 82.2 (2013): 284-289.
- Lisanti, Christopher J., et al. "What is the relative risk of urologic malignancy in microscopic hematuria patients after negative evaluation? A long-term population-based retrospective analysis of 8465 patients." Abdominal Radiology 48.3 (2023): 1011-1019.
- Stout, Thomas E., Michael Borofsky, and Ayman Soubra. "A visual scale for improving communication when describing gross hematuria." Urology 148 (2021): 32-36.
- Wieder JA: Pocket Guide to Urology. Sixth Edition. J.Wieder Medical: Oakland, CA, 2021.