Should I order additional tests or imaging or refer the patient to urology?

Urological Referral for Microscopic Hematuria with Bladder Wall Thickening and Diverticula

You should refer this patient to urology without ordering additional tests, as the combination of microscopic hematuria with previously documented bladder wall thickening and diverticula warrants specialist evaluation. 1, 2

Rationale for Urological Referral

The American Urological Association (AUA) guidelines clearly state that once benign causes of asymptomatic microscopic hematuria (AMH) have been ruled out, the presence of AMH should prompt a urologic evaluation 1. This is particularly important in your patient's case given:

1. Previous imaging findings: Bladder wall thickening and multiple diverticula are consistent with bladder outlet obstruction, which requires urological assessment 2

2. Risk of malignancy: Microscopic hematuria can be a sign of urinary tract malignancy, and the AUA recommends complete urological evaluation to rule out serious conditions 1

3. Need for cystoscopy: White light cystoscopy remains the standard for evaluation of microscopic hematuria and can only be performed by a urologist 1

Why Additional Imaging Is Not Needed First

While you might consider ordering another pelvic ultrasound, this would delay definitive evaluation:

• The urologist will likely perform cystoscopy regardless of additional imaging findings 1
• Bladder diverticula can lead to urinary stasis and increase the risk of recurrent UTIs 2
• The previously identified bladder abnormalities already warrant urological assessment

What the Urologist Will Likely Do

The urologist will likely perform:

1. Cystoscopy: To directly visualize the bladder wall thickening, diverticula, and assess for any suspicious lesions 1

2. Upper tract imaging: If not already performed, CT urography or alternative imaging based on patient factors 1

3. Treatment planning: For the bladder outlet obstruction, which may include:

   • Medical therapy (e.g., tamsulosin for BPH if applicable) 3
   • Evaluation for surgical intervention if needed

Special Considerations

• Age-based risk: If the patient is ≥60 years old, they fall into the high-risk category according to the AUA Microhematuria Risk Stratification System 1

• Smoking history: If the patient has >30 pack-years of smoking, they would also be considered high-risk 1

• Persistence: Persistent or recurrent microscopic hematuria after a negative previous workup requires shared decision-making regarding additional evaluation 1

Common Pitfalls to Avoid

1. Incomplete evaluation: Ordering only imaging without urological referral may miss important findings that require direct visualization

2. Delayed diagnosis: Microscopic hematuria can be a sign of bladder cancer or upper tract urothelial carcinoma, and delays in diagnosis can affect prognosis 1

3. Underestimating bladder diverticula: Diverticula can harbor stones, infection, or rarely malignancy, requiring direct visualization 2

By referring directly to urology, you ensure comprehensive evaluation of both the microscopic hematuria and the previously identified bladder abnormalities in the most efficient manner.