Evaluation and Management of Persistent Microscopic Hematuria

Initial Assessment and Risk Stratification

The American College of Radiology recommends that persistent microscopic hematuria, defined as ≥3 red blood cells per high-power field, requires thorough evaluation regardless of anticoagulant therapy, including patients on Pradaxa with hypertension and BPH 1, 2
The presence of BPH and hypertension are common benign causes of hematuria but should not preclude further evaluation, as recommended by the American College of Radiology 3
Patients should be stratified based on risk factors for urologic malignancy, including age, smoking history, degree of hematuria, and history of gross hematuria, as suggested by The Journal of Urology 2, 3
The degree of hematuria is a significant risk factor, with >25 RBC/HPF indicating high risk, according to American Family Physician 4

A complete urologic evaluation should include a comprehensive examination of urine and urinary sediment, assessment for dysmorphic red blood cells or red cell casts, testing for proteinuria and urinary tract infection, measurement of serum creatinine, radiologic imaging of the upper urinary tract, and cystoscopic examination of the urinary bladder, as recommended by American Family Physician 1, 4, 5
CT urography is preferred for comprehensive evaluation, while renal ultrasound may be used for initial screening in low-risk patients, and MR urography for patients who cannot receive CT contrast, according to The Journal of Urology 2, 3

Anticoagulation with Pradaxa may exacerbate bleeding from existing lesions, but it is not typically the primary cause of microscopic hematuria, and anticoagulation should not be assumed to be the cause without proper evaluation, as stated by the American College of Radiology 1, 3
For patients with persistent hematuria after negative initial evaluation, repeat urinalysis, urine cytology, and blood pressure determination at 6, 12, 24, and 36 months, and consider nephrology referral if hematuria persists with development of hypertension, proteinuria, or evidence of glomerular bleeding, as recommended by American Family Physician 6
The American College of Radiology and American Family Physician recommend against assuming hematuria is due to anticoagulation therapy or BPH without proper evaluation, and against omitting cystoscopy even in younger patients with microscopic hematuria, and emphasize the importance of continued monitoring for persistent hematuria 1, 3, 4, 6