What are the implications and management of hematuria with 9 RBCs/hpf in urine?

Management of 9 RBCs/HPF on Urinalysis

A finding of 9 RBCs/HPF represents microscopic hematuria that requires risk stratification and appropriate evaluation based on patient age, smoking history, and other risk factors—this level falls into the low-risk category (3-10 RBC/HPF) for malignancy but still warrants systematic assessment. 1, 2

Initial Confirmation and Assessment

Confirm the finding with microscopic urinalysis, as dipstick testing alone is insufficient for diagnosis and has limited specificity (65-99%). 2 The diagnosis of microscopic hematuria requires ≥3 RBCs/HPF on microscopic evaluation from a properly collected urine specimen. 1, 2

Rule Out Transient or Benign Causes

Before proceeding with extensive workup, exclude common reversible causes:

• If menstruation, viral illness, or vigorous exercise is suspected, repeat urinalysis after the cause is excluded. 1, 3
• If urinary tract infection is suspected (presence of leukocyte esterase, nitrites, or symptoms), obtain urine culture and repeat urinalysis 6 weeks after completing antibiotic treatment. 4 If hematuria resolves with treatment, no additional evaluation is necessary. 4
• Consider up to 3 repeated urinalyses to confirm persistence, as hematuria can be intermittent. 1

Risk Stratification

The 2025 AUA/SUFU guidelines stratify patients with 9 RBCs/HPF (falling in the 3-10 RBC/HPF range) as low risk if all of the following criteria are met: 1, 2

• Women age <50 years OR Men age <40 years
• Never smoker or <10 pack-years smoking history
• No additional risk factors for urothelial cancer
• No history of gross hematuria

Patients are upgraded to intermediate or high risk if they meet any of these criteria: 1, 3, 2

• Women age 50-59 years (intermediate) or ≥60 years (high)
• Men age 40-59 years (intermediate) or ≥60 years (high)
• Smoking history of 10-30 pack-years (intermediate) or >30 pack-years (high)
• History of gross hematuria (high risk)
• Occupational exposure to chemicals/dyes (benzenes or aromatic amines)
• History of urologic disorders or pelvic irradiation
• Irritative voiding symptoms

Determine Glomerular vs. Non-Glomerular Source

Examine urinary sediment for dysmorphic RBCs and red cell casts to differentiate glomerular from non-glomerular bleeding. 4, 3

• Glomerular bleeding: >80% dysmorphic RBCs, presence of RBC casts, significant proteinuria, or tea-colored urine. 3, 5
• Non-glomerular bleeding: >80% normal-appearing RBCs. 3

If glomerular source is suspected, measure serum creatinine and refer to nephrology, especially if proteinuria, hypertension, or declining renal function develops. 4, 3

Evaluation Based on Risk Category

Low-Risk Patients (9 RBCs/HPF with favorable demographics)

Shared decision-making regarding evaluation intensity is appropriate for low-risk patients. 1 Options include:

• Repeat urinalysis in 6 months: If negative, discharge from further hematuria evaluation given very low malignancy risk (0%-0.4%). 1, 2, 6
• Cystoscopy with urinary tract ultrasound: For patients who prefer more definitive evaluation or have anxiety about observation. 6

Intermediate-Risk Patients

Cystoscopy and upper tract imaging (CT urography preferred or renal ultrasound) are recommended. 4, 6

High-Risk Patients

Cystoscopy and axial upper urinary tract imaging (CT urography) are recommended. 1, 4, 6

Consider voided urine cytology in patients with risk factors for transitional cell carcinoma, particularly those with smoking history, occupational exposures, or irritative voiding symptoms. 4

Special Considerations

• Anticoagulation is NOT a reason to forgo evaluation, as these patients have similar malignancy risk to non-anticoagulated patients. 3, 2
• Family history of renal cell carcinoma or genetic renal tumor syndromes (von Hippel-Lindau, Birt-Hogg-Dube, hereditary papillary RCC, hereditary leiomyomatosis RCC, tuberous sclerosis) warrants upper tract imaging regardless of risk category. 1
• Gross hematuria reported on history (even if self-limited) upgrades risk to high and requires full urologic evaluation, as it carries 30-40% malignancy risk. 1, 3

Follow-Up After Negative Evaluation

If initial evaluation is negative and hematuria persists on repeat urinalysis, engage in shared decision-making regarding additional evaluation. 1 The diagnostic yield of repeated evaluations is very low, but select patients with multiple risk factors may benefit from continued monitoring. 1

Initiate further evaluation if the patient develops gross hematuria, significant increase in degree of microhematuria, or new urologic symptoms after a previously negative workup. 1