Management of Asymptomatic Microhematuria in a 65-Year-Old Smoker with Normal CT and Cystoscopy
The next step for a 65-year-old asymptomatic smoker man with microhematuria and normal CT and cystoscopy is to implement a surveillance protocol with repeat urinalysis, urine cytology, and blood pressure measurements at 6,12,24, and 36 months. 1, 2
Rationale for Surveillance
- Patients with a negative initial evaluation for asymptomatic microhematuria still require follow-up as some eventually develop significant urologic disease 1
- This is especially important in high-risk groups, including patients older than 40 years and those who use tobacco, as hematuria can precede the diagnosis of bladder cancer by many years 1, 3
- The risk of life-threatening lesions in patients with a negative initial evaluation is low, but continued monitoring is necessary due to the patient's risk factors (age and smoking history) 1, 2
Recommended Surveillance Protocol
- Repeat urinalysis at 6,12,24, and 36 months 1, 2
- Include voided urine cytology at these intervals 1, 3
- Monitor blood pressure at each follow-up visit 2
- If hematuria persists for 3 years without any concerning developments, the patient does not require further urologic monitoring 1
Indications for Immediate Re-evaluation
- Immediate urologic re-evaluation with consideration of cystoscopy, cytology, or repeat imaging is warranted if any of the following occur: 1, 2
- Gross hematuria
- Abnormal urinary cytology
- Irritative voiding symptoms in the absence of infection
Additional Considerations
- Consider nephrology referral if hematuria persists with development of hypertension, proteinuria, or evidence of glomerular bleeding (red cell casts, dysmorphic red blood cells) 1, 4
- Research shows a low yield of repeat evaluation (1.2% for bladder cancer on repeat cystoscopy and 1.3% for suspicious renal masses on repeat imaging), but surveillance remains important due to the patient's risk factors 5
- The combination of age >40 years and smoking history places this patient in a higher risk category, necessitating more vigilant follow-up 3, 4
Importance of Patient Education
- Inform the patient about the importance of completing the full surveillance protocol, even if symptoms resolve 2
- Emphasize the need to report any episodes of gross hematuria or new urinary symptoms immediately, as these require prompt re-evaluation 1, 2
- Explain that smoking cessation would be beneficial to reduce the risk of developing urologic malignancies 3