What is the recommended evaluation and management for a 69-year-old male patient with microscopic hematuria?

Evaluation and Management of Microscopic Hematuria in a 69-Year-Old Male

A 69-year-old male with microscopic hematuria should undergo a complete urologic evaluation including cystoscopy and CT urography due to his high risk for urinary tract malignancy. 1

Diagnostic Criteria and Initial Evaluation

Microscopic hematuria is defined as >3 RBC/HPF on microscopic evaluation of a properly collected urine specimen. For a 69-year-old male, this finding warrants thorough investigation due to high risk factors:

• Age >40 years (69 years old) places him in high-risk category 1
• Male gender increases risk of urologic malignancy 2

Initial evaluation should include:

1. Confirmation of microscopic hematuria with repeat urinalysis
2. Assessment for dysmorphic RBCs, proteinuria, and cellular casts 1
3. Urine culture to rule out infection as a benign cause 1
4. Measurement of serum creatinine and BUN to assess renal function 1
5. Blood pressure measurement and genitourinary examination 1

Risk Stratification

This patient falls into the high-risk category based on:

• Age (men ≥40 years) 1
• Potential smoking history (should be assessed)
• Potential occupational exposures (should be assessed)

Comprehensive Evaluation Algorithm

Step 1: Laboratory Testing

• Complete urinalysis with microscopic examination
• Urine culture
• Serum creatinine and BUN
• Protein-to-creatinine ratio (normal <0.2 g/g) 1

Step 2: Imaging

• CT urography is the preferred imaging study for high-risk patients with microscopic hematuria (sensitivity 92%, specificity 93%) 1
• Alternative imaging if contraindicated:
  • MR urography or ultrasound for patients with renal insufficiency or contrast allergy 1

Step 3: Cystoscopy

• Cystoscopy is indicated in this high-risk patient to evaluate the lower urinary tract 1, 2

Step 4: Specialist Referral

• Urology referral is mandatory for complete evaluation 1, 3
• Nephrology referral if there is evidence of:
  • Proteinuria (>500-1000 mg/24 hours)
  • Dysmorphic RBCs
  • Cellular casts
  • Renal insufficiency 1

Important Considerations and Pitfalls

1. Do not delay evaluation even if patient is on anticoagulants or antiplatelet agents - Anticoagulation does not explain away microscopic hematuria 1

2. Avoid incomplete evaluation - Studies show only 36% of primary care physicians refer patients with microscopic hematuria to urologists, potentially delaying diagnosis of serious conditions 3

3. Consider both urologic and nephrologic causes - Up to 5% of patients with asymptomatic microscopic hematuria have urinary tract malignancy 2

4. Follow-up is essential - If initial evaluation is negative:

   • Yearly urinalyses should be conducted if AMH persists
   • If AMH resolves (two consecutive negative annual urinalyses), no further evaluation is necessary
   • For persistent or recurrent AMH after negative workup, consider repeat evaluation within 3-5 years 1

5. Recognize the urgency - Delays in evaluation can be associated with decreased survival 1

Treatment Approach

Treatment should be directed at the underlying cause:

• Antibiotics for infection
• Management of urolithiasis if present
• Treatment of benign prostatic hyperplasia if diagnosed
• Appropriate oncologic management if malignancy is detected 1

This comprehensive approach ensures thorough evaluation of microscopic hematuria in this high-risk 69-year-old male patient, prioritizing detection of potentially serious conditions while following evidence-based guidelines.