What are the next steps in evaluating an 82-year-old woman with microscopic hematuria and negative cystoscopy and computed tomography (CT) scans?

Management of Microscopic Hematuria in an 82-Year-Old Woman with Negative Workup

For an 82-year-old woman with microscopic hematuria and negative cystoscopy and CT scans, a repeat urinalysis within 12 months is recommended to ensure safety, with persistent microscopic hematuria warranting consideration of additional evaluation. 1

Risk Assessment and Follow-up Strategy

Initial Considerations

• Age >60 years is a significant risk factor for urologic malignancy 1, 2
• Despite negative initial evaluation, continued surveillance is important due to:
  • Age-related increased risk of malignancy
  • Small possibility of missed pathology on initial workup

Recommended Next Steps

1. Repeat Urinalysis within 12 months

   • Primary safety measure recommended by AUA/SUFU guidelines 1
   • If negative: Consider case-by-case decision for future monitoring
   • If persistent microscopic hematuria: Proceed with additional evaluation

2. For Persistent Microscopic Hematuria on Follow-up

   • Consider shared decision-making regarding need for additional evaluation 1
   • Options include:
     • Additional imaging of urinary tract 1
     • Consideration of urine cytology if irritative voiding symptoms or risk factors for carcinoma in situ exist 1

Additional Considerations

Upper Tract Evaluation

• If patient has family history of renal cell carcinoma or genetic renal tumor syndrome:
  • Additional upper tract imaging is warranted regardless of risk category 1
  • Options include CT urogram, MR urogram, or retrograde pyelography 1

Role of Urine-Based Markers

• Routine use of urine cytology or urine-based tumor markers is not recommended for initial evaluation or as adjunctive tests with normal cystoscopy 1
• Exception: Consider urine cytology for patients with persistent microscopic hematuria who have irritative voiding symptoms or risk factors for carcinoma in situ 1

Risk of Malignancy After Negative Workup

• Studies show low incidence of malignancies after an initial negative evaluation 1
• However, in one study, 1.2% of patients with persistent or recurrent microscopic hematuria were found to have bladder tumors on repeat evaluation 1

Important Caveats

• Do not attribute microscopic hematuria solely to anticoagulant therapy without proper evaluation 2
• Do not assume hematuria is due to UTI without supporting evidence of infection 2
• If the patient develops gross hematuria, significant increase in degree of microscopic hematuria, or new urologic symptoms, prompt further evaluation is required 1
• Consider nephrology referral if there are signs of kidney disease (proteinuria, elevated creatinine, etc.) 2

Follow-up Schedule

• Initial repeat urinalysis: Within 12 months
• If persistent microscopic hematuria: Consider repeat evaluation at 6,12,24, and 36 months based on risk stratification 2

This approach balances the small risk of missed pathology against the anxiety, cost, inconvenience, and risks of ongoing monitoring and repeated investigations.