Assessment of Asymptomatic Microscopic Hematuria in Adults



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Am Fam Physician. 2013 Dec 1;88(11):747-754.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

  Patient information: A handout on microscopic hematuria is available at http://familydoctor.org/familydoctor/en/diseases-conditions/microscopic-hematuria.html.

  Related letter: Consider Thin Basement Membrane Nephropathy as a Possible Cause of Asymptomatic Microscopic Hematuria

Author disclosure: No relevant financial affiliations.

Although routine screening for bladder cancer is not recommended, microscopic hematuria is often incidentally discovered by primary care physicians. The American Urological Association has published an updated guideline for the management of asymptomatic microscopic hematuria, which is defined as the presence of three or more red blood cells per high-power field visible in a properly collected urine specimen without evidence of infection. The most common causes of microscopic hematuria are urinary tract infection, benign prostatic hyperplasia, and urinary calculi. However, up to 5% of patients with asymptomatic microscopic hematuria are found to have a urinary tract malignancy. The risk of urologic malignancy is increased in men, persons older than 35 years, and persons with a history of smoking. Microscopic hematuria in the setting of urinary tract infection should resolve after appropriate antibiotic treatment; persistence of hematuria warrants a diagnostic workup. Dysmorphic red blood cells, cellular casts, proteinuria, elevated creatinine levels, or hypertension in the presence of microscopic hematuria should prompt concurrent nephrologic and urologic referral. The upper urinary tract is best evaluated with multiphasic computed tomography urography, which identifies hydronephrosis, urinary calculi, and renal and ureteral lesions. The lower urinary tract is best evaluated with cystoscopy for urethral stricture disease, benign prostatic hyperplasia, and bladder masses. Voided urine cytology is no longer recommended as part of the routine evaluation of asymptomatic microscopic hematuria, unless there are risk factors for malignancy.

In its 2011 recommendation statement, the U.S. Preventive Services Task Force did not find sufficient evidence for or against screening for bladder cancer in asymptomatic adults.1 Despite this, microscopic hematuria is often found incidentally during routine health screenings, with a prevalence of about 2% to 31%.26 Because primary care physicians commonly are the first to recognize asymptomatic microscopic hematuria, an evidence-based approach to the evaluation of hematuria is necessary. In 2012, the American Urological Association (AUA) published an updated guideline on the diagnosis, evaluation, and follow-up of asymptomatic microscopic hematuria in adults.6 Based on the guideline, this article describes the current approaches to diagnosis, follow-up, and referral for patients with asymptomatic microscopic hematuria.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

There is insufficient evidence to recommend screening urinalysis for the detection of bladder cancer in the absence of clinical indicators.

C

1

Further evaluation is recommended for individuals with three or more red blood cells per high-power field in a properly collected urine specimen in the absence of infection.

C

6

Concurrent nephrologic and urologic referral is indicated in the presence of hypertension, elevated creatinine level, and dysmorphic red blood cells, cellular casts, or proteinuria on urinalysis.

C

6, 21, 22

Computed tomography urography is the preferred method for radiologic imaging in the evaluation of microscopic hematuria.

C

6, 24, 27, 28

Urine cytology and other bladder tumor markers are not recommended for the initial evaluation of microscopic hematuria.

C

6, 4143


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

There is insufficient evidence to recommend screening urinalysis for the detection of bladder cancer in the absence of clinical indicators.

C

1

Further evaluation is recommended for individuals with three or more red blood cells per high-power field in a properly collected urine specimen in the absence of infection.

C

6

Concurrent nephrologic and urologic referral is indicated in the presence of hypertension, elevated creatinine level, and dysmorphic red blood cells, cellular casts, or proteinuria on urinalysis.

C

6, 21, 22

Computed tomography urography is the preferred method for radiologic imaging in the evaluation of microscopic hematuria.

C

6, 24, 27, 28

Urine cytology and other bladder tumor markers are not recommended for the initial evaluation of microscopic hematuria.

C

6, 4143


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http:

The Authors

VICTORIA J. SHARP, MD, MBA, is a clinical professor of urology and family medicine, and chief of staff at the University of Iowa Hospitals and Clinics in Iowa City.

KERRI T. BARNES, MD, MPH, is a fifth-year urology resident at the University of Iowa Hospitals and Clinics.

BRADLEY A. ERICKSON, MD, MS, is a clinical assistant professor of urology at the University of Iowa Hospitals and Clinics.

Address correspondence to Victoria J. Sharp, MD, MBA, University of Iowa, 200 Hawkins Dr., 3 RCP, Iowa City, IA 52242-1089 (e-mail: victoria-sharp@uiowa.edu). Reprints are not available from the authors.

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