Management of Microscopic Hematuria

Initial Assessment

For a patient with microscopic hematuria, confirm the finding with microscopic examination of urinary sediment and proceed with a complete urologic evaluation including imaging and cystoscopy due to the patient's age, as recommended by the American College of Physicians 1, 2
Confirm the dipstick finding with microscopic examination of urinary sediment from a freshly voided, clean-catch, midstream urine specimen, as dipstick testing has limited specificity (65-99%) 3
The recommended definition of microscopic hematuria is three or more red blood cells per high-power field on microscopic evaluation, according to the American Academy of Family Physicians 4
Exclude benign causes of hematuria including vigorous exercise, infection, trauma, menstruation, or recent urologic procedures, as suggested by the Journal of the American College of Radiology 5
Obtain urine culture to rule out urinary tract infection as a potential cause, as recommended by the American College of Physicians 2

Age over 40 years is considered a risk factor for significant urologic disease, including malignancy, according to the American Academy of Family Physicians 6
Other risk factors to assess include smoking history, occupational exposure to chemicals or dyes, history of gross hematuria, irritative voiding symptoms, and history of urologic disorders, as suggested by the American Academy of Family Physicians 6
The risk of malignancy in patients with microscopic hematuria ranges from 2.6% to 4%, compared to 30-40% in those with gross hematuria, as reported by the Journal of the American College of Radiology 5

Assess for signs of primary renal disease, including significant proteinuria, dysmorphic red blood cells, red cell casts, or elevated serum creatinine, as recommended by the American Academy of Family Physicians 7
If these signs are present, consider nephrology referral for evaluation of glomerular disease, according to the American Academy of Family Physicians 7
If no signs of primary renal disease are present, proceed with urologic evaluation, as suggested by the American Academy of Family Physicians 7

CT urography (CTU) as the preferred imaging modality for comprehensive evaluation of the upper urinary tract, as recommended by the Journal of the American College of Radiology 5
Cystoscopy for direct visualization of the bladder mucosa, urethra, and ureteral orifices, according to the American Academy of Family Physicians 4
Flexible cystoscopy is preferred over rigid cystoscopy as it causes less pain and has fewer post-procedure symptoms, as suggested by the American Academy of Family Physicians 4
Do not routinely obtain urinary cytology or other urine-based molecular markers for bladder cancer detection in the initial evaluation, as recommended by the American College of Physicians 2

If the initial evaluation is negative, repeat urinalysis, blood pressure determination, and possibly urine cytology at 6, 12, 24, and 36 months, as suggested by the American Academy of Family Physicians 4
Immediate urologic reevaluation is warranted if any of the following occur: gross hematuria, abnormal urinary cytology, or irritative voiding symptoms in the absence of infection, according to the American Academy of Family Physicians 4
If none of these occurs within three years, no further urologic monitoring is required, as recommended by the American Academy of Family Physicians 4
Consider nephrology referral if hematuria persists and hypertension, proteinuria, or evidence of glomerular bleeding develops, as suggested by the American Academy of Family Physicians 4

Do not attribute hematuria solely to antiplatelet or anticoagulant therapy if the patient is taking these medications, as recommended by the American College of Physicians 2
Do not defer evaluation in patients over 40 years of age, as they are at higher risk for significant urologic disease, according to the American Academy of Family Physicians 6
The prevalence of asymptomatic microscopic hematuria in older men can be as high as 21%, with a higher risk for significant urologic disease, as reported by the American Academy of Family Physicians 6