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Awaiting dx & risk assessment
Don’t order UA to screen for CA in asymptomatic pts;1 dx microhematuria based on presence of RBCs on micro UA, not dipstick;1,2 assess for potential benign causes and stratify level of risk for CA2 - Dx microhematuria if ≥3 RBCs/hpf on single micro UA1,2
- If trace blood (or worse) on urine dipstick, perform formal micro UA before pursuing further eval1,2
- Perform H&P (incl vulvovaginal exam), other tests prn to assess for medical renal dz, gyn source, or nonmalignant GU causes of microhematuria2
- Consider DDx: benign prostatic enlargement, nephrolithiasis, urinary tract infxn, urethral strictures & diverticula, exposure to trauma, recent urological procedures/catheterization2
- If dx w/ gyn or nonmalignant source (eg, menstruation, UTI, stones, etc), repeat UA after resolution/tx to confirm resolution of microhematuria; proceed to risk stratification if UA still (+)2
- Stratify level of risk using the AUA Microhematuria Risk Stratification System2 (table below) to determine next steps for eval; ask about hx of gross hematuria and refer for urologic eval if (+)1
- If medical renal dz suspected, refer to nephrology, but still perform risk-based eval, per AUA2
AUA Microhematuria Risk Stratification System2 Footnotes 1ACP 2016. Nielsen M and Qaseem A, et al. Hematuria as a Marker of Occult Urinary Tract Cancer: Advice for High-Value Care From the American College of Physicians. Ann Intern Med. 2016. Apr 5:164(7):488-97. PubMed® abstract
2AUA 2020. Barocas DA, et al. Microhematuria: AUA/SUFU Guideline. American Urological Association. J Urol. 2020. Oct:204(4):778-786. PubMed® abstract
H&P, UA clues to benign conditions in DDx include:
• UTI: fever, dysuria
• Nephrolithiasis: flank pain
• Menstruation: menstrual cycle hx; cath urine may be helpful
• BPH, urethral stricture: obstructive urinary sx
• Medical renal dz: hypertension, proteinuria, dysmorphic RBCs on UA -
Confirmed microhematuria dx, awaiting initial eval
Employ patient-centered, shared decision-making in determining plan of care; observation may be appropriate, but referral for cystoscopy and imaging is also reasonable; antiplatelet/anticoagulant tx does not change recs - Discuss options w/ pts: repeat UA in 6mo vs refer for cystoscopy + imaging;1 per ACP, may consider cystoscopy + imaging in any pt w/ microhematuria & no obvious cause;2 ACOG/AUGS recommends against further eval for women in this group3
- If repeat UA (+) in low risk pt who initially chose not to pursue cystoscopy + imaging, reclassify as intermediate or high risk & follow corresponding recs1
- Order renal US as initial imaging, per AUA;1 however, ACR states renal US usually inappropriate, unless pt is pregnant, & favors CT abd/pelvis w/o IV contrast;4 MR urogram w/o IV contrast also an option in pregnant pts4
- Pursue further eval even if pt on antiplatelet or anticoagulant tx1,2
- Perform upper tract imaging if FHx of renal cell carcinoma or genetic renal tumor syndrome, even if low risk1
- Don’t obtain urine cytology or other urine-based molecular markers for bladder CA in initial eval1,2
Footnotes 1 AUA 2020. Barocas DA, et al. Microhematuria: AUA/SUFU Guideline. American Urological Association. J Urol. 2020. Oct:204(4):778-786. PubMed® abstract
2 ACP 2016. Nielsen M and Qaseem A, et al. Hematuria as a Marker of Occult Urinary Tract Cancer: Advice for High-Value Care From the American College of Physicians. Ann Intern Med. 2016. Apr 5:164(7):488-97. PubMed® abstract
3 ACOG 2017. Asymptomatic Microscopic Hematuria in Women. Committee Opinion No. 703. Committee on Gynecologic Practice, American Urogynecologic Society. Obstet Gynecol. 2017 Ju;129(6):e168-e172. PubMed® abstract
4 ACR 2019. American College of Radiology ACR Appropriateness Criteria® Hematuria. Revised 2019. PDF
Evaluation of upper and lower tract is warranted, though CA risk is still relatively low (1.3%-1.6%);1 antiplatelet/anticoagulant tx does not change recs1,2 - Refer for cystoscopy + imaging;1 per ACP, may consider cystoscopy + imaging in any pt w/ microhematuria & no obvious cause;2 ACOG/AUGS recommend against further eval for women 35-50y w/ ≤25 RBC/hpf3
- Order renal US as initial imaging, per AUA;1 ACR favors CT urogram w/ & w/o IV contrast, but renal US, CT abd/pelvis w/o IV contrast, CT abd/pelvis w/ & w/o IV contrast, MR urogram w/ & w/o IV contrast may also be appropriate; MR urogram w/o IV contrast also an option in pregnant pts4
- Pursue further eval even if pt on antiplatelet or anticoagulant tx1,2
- Don’t obtain urine cytology or other urine-based molecular markers for bladder CA in initial eval1,2
Footnotes 1 AUA 2020. Barocas DA, et al. Microhematuria: AUA/SUFU Guideline. American Urological Association. J Urol. 2020. Oct:204(4):778-786. PubMed® abstract
2 ACP 2016. Nielsen M and Qaseem A, et al. Hematuria as a Marker of Occult Urinary Tract Cancer: Advice for High-Value Care From the American College of Physicians. Ann Intern Med. 2016. Apr 5:164(7):488-97. PubMed® abstract
3 ACOG 2017. Asymptomatic Microscopic Hematuria in Women. Committee Opinion No. 703. Committee on Gynecologic Practice, American Urogynecologic Society. Obstet Gynecol. 2017 Ju;129(6):e168-e172. PubMed® abstract
4 ACR 2019. American College of Radiology ACR Appropriateness Criteria® Hematuria. Revised 2019. PDF
Evaluation of upper and lower tract is recommended, as CA risk is significant (10.8%-11.1%);1,2 antiplatelet/anticoagulant tx does not change recs1,3 - Refer for cystoscopy + axial imaging;1,2 per ACP, may consider cystoscopy + imaging in any pt w/ microhematuria & no obvious cause3
- Order CT urogram w/ & w/o IV contrast as initial imaging, per AUA1 & ACR;4 both also consider MR urogram w/ & w/o IV contrast as option; MR urogram w/o IV contrast is an option in pregnant pts per ACR,4 but AUA recommends renal US, then axial imaging post partum1
- Pursue further eval even if pt on antiplatelet or anticoagulant tx1,3
- Don’t obtain urine cytology or other urine-based molecular markers for bladder CA in initial eval1,3
Footnotes 1 AUA 2020. Barocas DA, et al. Microhematuria: AUA/SUFU Guideline. American Urological Association. J Urol. 2020. Oct:204(4):778-786. PubMed® abstract
For pts w/ contraindications to CT and MR urography, imaging of the renal cortex w/ either noncontrast CT or renal US to assess the renal cortex + retrograde pyelography (RPG) to assess the urothelium.
2 ACOG 2017. Asymptomatic Microscopic Hematuria in Women. Committee Opinion No. 703. Committee on Gynecologic Practice, American Urogynecologic Society. Obstet Gynecol. 2017 Ju;129(6):e168-e172. PubMed® abstract
3 ACP 2016. Nielsen M and Qaseem A, et al. Hematuria as a Marker of Occult Urinary Tract Cancer: Advice for High-Value Care From the American College of Physicians. Ann Intern Med. 2016. Apr 5:164(7):488-97. PubMed® abstract
4 ACR 2019. American College of Radiology ACR Appropriateness Criteria® Hematuria. Revised 2019. PDF
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Consider additional evaluation in pts w/ persistent or recurrent microhematuria; can d/c UA monitoring and evaluation in select pts - Repeat UA w/in 12mo; if subsequent UA(-), may d/c eval1
- If microhematuria persists/recurs, engage in shared decision-making re further eval; pursue additional imaging, if renal US used initially1
- If pt develops gross hematuria,1,2 ↑degree of hematuria or new urologic sx, initiate further eval1
- Consider urine cytology in pts w/ persistent hematuria and irritative voiding sx or risk factors for carcinoma in situ; evidence insufficient for urine-based tumor markers1
Footnotes 1 AUA 2020. Barocas DA, et al. Microhematuria: AUA/SUFU Guideline. American Urological Association. J Urol. 2020. Oct:204(4):778-786. PubMed® abstract
2 ACP 2016. Nielsen M and Qaseem A, et al. Hematuria as a Marker of Occult Urinary Tract Cancer: Advice for High-Value Care From the American College of Physicians. Ann Intern Med. 2016. Apr 5:164(7):488-97. PubMed® abstract
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