From the Guidelines
For a 69-year-old female with microscopic hematuria and a normal CT scan of the abdomen, further workup is still necessary to rule out underlying urologic malignancy. The recommended approach includes a complete urologic evaluation consisting of cystoscopy to directly visualize the bladder and urethra, as well as urine cytology to check for malignant cells 1. Additionally, a comprehensive medical history review should focus on medication use (especially anticoagulants), recent infections, and family history of urologic conditions. Laboratory tests should include urinalysis with microscopy, urine culture, serum creatinine, and complete blood count. If not already performed, renal ultrasound may be considered to evaluate the kidneys more thoroughly. This comprehensive workup is important because microscopic hematuria in older adults carries a significant risk of underlying urologic malignancy (approximately 5-10%), even with a normal CT scan 1. While the CT has ruled out many potential causes, bladder cancer and other urologic conditions may still be present and require direct visualization. Early detection of urologic malignancies significantly improves treatment outcomes, making thorough evaluation essential despite reassuring initial imaging. The American Urological Association guidelines recommend cystoscopy and upper urinary tract imaging for all adults with asymptomatic microscopic hematuria, especially those over 35 years old 1. Given the patient's age and the presence of microscopic hematuria, it is crucial to follow these guidelines to ensure timely diagnosis and treatment of any potential underlying conditions. A study published in the Journal of the American College of Radiology emphasizes the importance of a thorough evaluation, including cystoscopy and urine cytology, for patients with microhematuria, particularly those with risk factors such as age and smoking history 1. Therefore, a comprehensive urologic evaluation, including cystoscopy and urine cytology, is essential for this patient.
From the Research
Evaluation of Microscopic Hematuria
In a 69-year-old female with microscopic hematuria and a normal CT scan of the abdomen, the following workup is needed:
- Initial evaluation with renal ultrasound (US) and cystoscopy, as well as urinalysis, urine culture, and cytology, is recommended 2
- If the initial evaluation is negative, and microhematuria persists for 3 months without a definitive diagnosis, further evaluation with intravenous urography (IVU) may be beneficial 2
- The American Urological Association guidelines for imaging of patients with asymptomatic microscopic hematuria should be followed, which may include CT urography (CTU) in certain cases 3
- Patients with proteinuria, red cell casts, and elevated serum creatinine levels should be referred promptly to a nephrology subspecialist 4
- Urine cytology plus intravenous urography, computed tomography, or ultrasonography should be used to evaluate patients with asymptomatic microscopic hematuria or with hematuria persisting after treatment of urinary tract infection 4
Considerations for Imaging
- CTU may be performed for patients who meet the American Urological Association criteria for radiologic evaluation, but the yield of CTU for upper urinary tract malignancy is low 3
- In some cases, CTU may be performed for patients who do not meet the criteria for radiologic evaluation, highlighting the need for careful consideration of imaging guidelines 3
- The combination of cystoscopy and renal US along with urinalysis, urine culture, and cytology is a good initial evaluation in patients with microhematuria 2