What is the next step in managing a patient with microscopic hematuria, rare urine bacteria, and squamous epithelial cells in urine, but no RBC or WBC?

Repeat Urinalysis to Confirm True Microscopic Hematuria

Your initial urinalysis shows a critical discrepancy: the report states "microscopic hematuria" but microscopic examination reveals NO RBCs—this is not hematuria and requires confirmation with repeat microscopic urinalysis before any further workup.

Understanding the Discrepancy

• The presence of "microscopic hematuria" on a report without actual RBCs visible on microscopic examination suggests either a false-positive dipstick result or contamination 1, 2
• Dipstick positivity must always be confirmed with microscopic analysis showing ≥3 RBCs per high-power field before initiating any hematuria workup 1, 3
• Dipstick testing has limited specificity (65-99%) and can produce false positives from myoglobin, hemoglobin, or other substances 4, 2
• The squamous epithelial cells (1-5) suggest possible contamination from the collection technique 2

Immediate Next Steps

Repeat urinalysis with proper collection technique:

• Obtain a freshly voided, clean-catch, midstream urine specimen for microscopic examination 4
• Ensure the specimen is not collected during menstruation (if applicable) 3, 2
• Avoid collection within 48 hours of vigorous exercise or sexual activity 3
• The specimen should be examined fresh, not stored 4

Definition of True Microscopic Hematuria

• True microscopic hematuria requires ≥3 RBCs per high-power field on microscopic evaluation of urinary sediment from two of three properly collected specimens 4, 2
• A single urinalysis showing no RBCs does NOT meet criteria for hematuria evaluation 4

If Repeat Testing Confirms No RBCs

• No further hematuria workup is indicated if repeat microscopic examination continues to show 0 RBCs 4, 1
• The rare bacteria noted may represent contamination given the absence of WBCs and should not trigger treatment in an asymptomatic patient 3
• Reassure the patient and return to routine care 3

If Repeat Testing Shows ≥3 RBCs/HPF

Only if confirmed hematuria is present on repeat testing should you proceed with:

• Risk stratification based on age, smoking history, and occupational exposures 1, 3
• Examination of urinary sediment for dysmorphic RBCs (>80% suggests glomerular source) 3, 2
• Assessment for proteinuria and serum creatinine to evaluate for glomerular disease 3, 2
• Exclusion of benign causes including urinary tract infection (obtain culture if suspected) 3

Risk Factors Requiring Enhanced Evaluation

• Age >40 years (women) or >60 years (men) 1, 3
• Smoking history >10 pack-years 1, 3
• Occupational exposure to benzenes or aromatic amines 4, 3
• History of gross hematuria, irritative voiding symptoms, or pelvic irradiation 4, 3

Common Pitfall to Avoid

• Never proceed with cystoscopy, imaging, or urologic referral based on dipstick results alone without microscopic confirmation of ≥3 RBCs/HPF 1, 3, 2
• Do not attribute dipstick positivity to anticoagulation without confirming true hematuria microscopically 1, 3
• The presence of rare bacteria without pyuria (WBCs) in an asymptomatic patient does not warrant antibiotic treatment 3