Evaluation and Management of Microscopic Hematuria

Introduction to Microscopic Hematuria

The American Urological Association recommends that patients with microscopic hematuria should undergo a comprehensive urological evaluation, as the presence of hematuria may indicate a underlying malignancy, with approximately 3% of patients having a genitourinary malignancy, and this risk increases substantially with specific risk factors 1, 2
The presence of urinary tract infection does not exclude the possibility of a underlying malignancy, and therefore, a comprehensive evaluation is necessary, even after treatment of the infection 1, 2

Patients with a history of smoking >30 pack-years are at increased risk of malignancy and should undergo a comprehensive urological evaluation 1, 3
Patients with a family history of genitourinary cancer, or exposure to certain chemicals, such as benzene or aromatic amines, are also at increased risk 1, 3
Patients with irritative voiding symptoms, such as dysuria or frequency, should also undergo a comprehensive evaluation 1

The initial evaluation should include a urinalysis with confirmation of microscopic hematuria, with ≥3 red blood cells per high power field, and a urine culture, if possible, before starting antibiotics 1, 2, 3
If the culture is positive, treatment with appropriate antibiotics should be initiated, and a repeat urinalysis should be performed 6 weeks after treatment to confirm resolution of hematuria 1
If hematuria persists, or if the patient has high-risk factors, a comprehensive urological evaluation, including cystoscopy, imaging of the upper urinary tract, and urinalysis, should be performed 1, 3

Cystoscopy is obligatory for all patients ≥40 years with microscopic hematuria, and should be performed by a urologist 3
Imaging of the upper urinary tract, preferably with CT urography, should also be performed to rule out upper tract malignancy 1, 3
Urinalysis, including cytology, should be performed to rule out bladder cancer 3

Patients with resolved hematuria should be followed up with repeat urinalysis at 6, 12, 24, and 36 months, and should be monitored for the development of new symptoms or signs of malignancy 1, 3
Patients with persistent hematuria should undergo a comprehensive urological evaluation, and should be followed up regularly to monitor for the development of malignancy 1, 3

Patients with dysmorphic red blood cells >80% with hematuria, or significant proteinuria, should be referred to a nephrologist for further evaluation and management 1, 3
Patients with elevated serum creatinine or declining renal function should also be referred to a nephrologist 3