What are the next steps for a 43-year-old patient presenting with microscopic hematuria (blood in urine)?

Management of Microscopic Hematuria in a 43-Year-Old Patient

For a 43-year-old patient with microscopic hematuria (10 RBCs), you should confirm the finding with microscopic examination of urinary sediment and proceed with a complete urologic evaluation including imaging and cystoscopy due to the patient's age. 1

Initial Assessment

• Confirm the dipstick finding with microscopic examination of urinary sediment from a freshly voided, clean-catch, midstream urine specimen, as dipstick testing has limited specificity (65-99%) 1
• The recommended definition of microscopic hematuria is three or more red blood cells per high-power field on microscopic evaluation 1
• Exclude benign causes of hematuria including vigorous exercise, infection, trauma, menstruation, or recent urologic procedures 1
• Obtain urine culture to rule out urinary tract infection as a potential cause 1

Risk Stratification

• Age over 40 years is considered a risk factor for significant urologic disease, including malignancy 1
• Other risk factors to assess include smoking history, occupational exposure to chemicals or dyes, history of gross hematuria, irritative voiding symptoms, and history of urologic disorders 1
• The risk of malignancy in patients with microscopic hematuria ranges from 2.6% to 4%, compared to 30-40% in those with gross hematuria 1

Diagnostic Evaluation

• Assess for signs of primary renal disease, including significant proteinuria, dysmorphic red blood cells, red cell casts, or elevated serum creatinine 1
• If these signs are present, consider nephrology referral for evaluation of glomerular disease 1
• If no signs of primary renal disease are present, proceed with urologic evaluation 1

Urologic Evaluation Should Include:

• CT urography (CTU) as the preferred imaging modality for comprehensive evaluation of the upper urinary tract 1
• Cystoscopy for direct visualization of the bladder mucosa, urethra, and ureteral orifices 1
• Flexible cystoscopy is preferred over rigid cystoscopy as it causes less pain and has fewer post-procedure symptoms 1
• Do not routinely obtain urinary cytology or other urine-based molecular markers for bladder cancer detection in the initial evaluation 1

Follow-up Recommendations

• If the initial evaluation is negative, repeat urinalysis, blood pressure determination, and possibly urine cytology at 6,12,24, and 36 months 1
• Immediate urologic reevaluation is warranted if any of the following occur: gross hematuria, abnormal urinary cytology, or irritative voiding symptoms in the absence of infection 1
• If none of these occurs within three years, no further urologic monitoring is required 1
• Consider nephrology referral if hematuria persists and hypertension, proteinuria, or evidence of glomerular bleeding develops 1

Important Caveats

• Do not attribute hematuria solely to antiplatelet or anticoagulant therapy if the patient is taking these medications 1
• Do not defer evaluation in patients over 40 years of age, as they are at higher risk for significant urologic disease 1
• The prevalence of asymptomatic microscopic hematuria in older men can be as high as 21%, with a higher risk for significant urologic disease 1
• Early detection of urologic malignancy significantly impacts mortality and morbidity 2