Evaluation and Management of Microscopic Hematuria

Initial Evaluation

The American Urological Association recommends beginning with a detailed history focusing on malignancy risk factors, physical examination including blood pressure, and serum creatinine measurement to determine whether the patient requires urologic evaluation, nephrologic evaluation, or both 1
Obtain microscopic urinalysis to verify ≥3 red blood cells per high-power field on two of three properly collected specimens, as recommended by the American Academy of Family Physicians 2, 3

The American Urological Association recommends using the 2025 AUA/SUFU system to stratify patients into low, intermediate, or high risk for malignancy, based on factors such as age, sex, smoking history, and number of red blood cells per high-power field 1
Low-risk patients have a malignancy risk of 0%-0.4%, intermediate-risk patients have a risk of 0.2%-3.1%, and high-risk patients have a risk of 1.3%-6.3% 1

The American Academy of Family Physicians recommends comprehensive urinalysis with sediment examination to determine the number of RBCs per high-power field, and to assess RBC morphology and look for red cell casts 2, 3
Measure serum creatinine, as recommended by the American Urological Association 1, 2

For glomerular source suspected, refer to nephrology for evaluation of primary renal disease, which may include assessment for systemic diseases and consideration of renal biopsy, as recommended by the American Academy of Family Physicians 2, 3
For non-glomerular source, urologic evaluation is required, with cystoscopy and upper urinary tract imaging (CT urography preferred) for intermediate- and high-risk patients, as recommended by the American College of Radiology and the American Urological Association 1, 7

Repeat urinalysis at 6, 12, 24, and 36 months, and monitor blood pressure at each visit, as recommended by the American Urological Association 5, 6
Consider nephrology referral if hematuria persists with development of hypertension, proteinuria, or evidence of glomerular bleeding, as recommended by the American Academy of Family Physicians 2, 5, 6