What are the steps for the initial visit of a patient with microscopic hematuria?

Initial Visit Evaluation for Microscopic Hematuria

Begin with a detailed history focusing on malignancy risk factors, physical examination including blood pressure, and serum creatinine measurement to determine whether the patient requires urologic evaluation, nephrologic evaluation, or both. 1

Step 1: Confirm True Hematuria

• Obtain microscopic urinalysis to verify ≥3 red blood cells per high-power field on two of three properly collected specimens 1
• Do not rely solely on dipstick testing, as it can yield false positives from myoglobinuria, hemoglobinuria, or menstrual contamination 2
• In women, perform urethral and vaginal examination to exclude local causes; obtain catheterized specimen if clean-catch cannot be reliably obtained due to vaginal contamination or obesity 1
• In uncircumcised men, retract foreskin to expose glans penis; if phimosis present, obtain catheterized specimen 1

Step 2: Exclude Benign Transient Causes

• Rule out menstruation, vigorous exercise, sexual activity, viral illness, trauma, and infection 1, 3
• If urinary tract infection suspected, obtain urine culture before antibiotics, treat if positive, then repeat urinalysis 6 weeks post-treatment 2, 4
• If benign cause identified, repeat urinalysis 48 hours after cessation of the activity 1, 4
• No additional evaluation warranted if hematuria resolves after addressing benign cause 1

Step 3: Detailed History and Physical Examination

Obtain the following specific information:

• Age and sex for risk stratification 1
• Detailed smoking history with pack-year quantification (never smoker/<10 pack-years/10-30 pack-years/>30 pack-years) 1
• Occupational exposures to chemicals, dyes, benzenes, or aromatic amines 1, 4
• History of gross hematuria (even if not currently present) 1
• Irritative voiding symptoms 1, 4
• Previous urologic disorders or recurrent urinary tract infections 1, 4
• Family history of urologic malignancies 1
• Measure blood pressure at initial visit 1

Step 4: Laboratory Analysis

• Comprehensive urinalysis with sediment examination to determine number of RBCs per high-power field 1
• Assess RBC morphology: >80% dysmorphic RBCs suggests glomerular origin; >80% normal RBCs suggests lower urinary tract origin 1
• Look for red cell casts (indicates glomerular disease) 1, 3
• Test for proteinuria: if ≥1+ on dipstick, obtain 24-hour urine collection to quantitate 1, 3
• Measure serum creatinine 1

Step 5: Risk Stratification Using 2025 AUA/SUFU System

Low/Negligible Risk (0%-0.4% malignancy risk) - ALL criteria must be met: 1

• 3-10 RBC/HPF
• Women <60 years OR men <40 years
• Never smoker or <10 pack-years
• No additional risk factors for urothelial cancer

Intermediate Risk (0.2%-3.1% malignancy risk) - ONE or more criteria: 1

• 11-25 RBC/HPF
• Women ≥60 years OR men 40-59 years
• 10-30 pack-years smoking history
• Any additional risk factors for urothelial cancer

High Risk (1.3%-6.3% malignancy risk) - ONE or more criteria: 1

• 25 RBC/HPF

• Men ≥60 years (women cannot be categorized as high-risk based on age alone)

• 30 pack-years smoking history

• One or more risk factors PLUS any high-risk feature

Step 6: Determine Evaluation Pathway

If Glomerular Source Suspected (any of the following):

• Proteinuria >500 mg/24 hours 1, 3

• 80% dysmorphic RBCs 1, 3

• Red cell casts present 1, 3
• Elevated serum creatinine 1

Action: Refer to nephrology for evaluation of primary renal disease, which may include assessment for systemic diseases (lupus, vasculitis, infections) and consideration of renal biopsy 1

If Non-Glomerular Source (Urologic Evaluation Required):

For Low-Risk Patients: 1

• Shared decision-making regarding repeat urinalysis in 6 months versus proceeding with cystoscopy and urinary tract ultrasound

For Intermediate-Risk Patients: 1

• Cystoscopy and upper urinary tract imaging (CT urography preferred by ACR with 92% sensitivity and 93% specificity) 1, 2
• Voided urinary cytology may be performed 1

For High-Risk Patients: 1

• Cystoscopy (mandatory for bladder visualization) 2
• CT urography for upper tract imaging 1, 2
• Voided urinary cytology recommended 1

Critical Pitfalls to Avoid

• Never attribute microscopic hematuria solely to anticoagulation or antiplatelet therapy without complete evaluation—these medications may unmask pathology but do not cause hematuria 2, 4
• Do not skip urologic evaluation even if glomerular disease identified—both conditions can coexist 2
• Women are significantly underreferred (8-28% vs 36-47% in men) despite having similar evaluation requirements 2
• Patients with isolated hematuria (negative initial urologic evaluation, no glomerular bleeding) still require follow-up for development of hypertension, renal insufficiency, or proteinuria 1

Follow-Up for Negative Initial Evaluation

• Repeat urinalysis at 6,12,24, and 36 months 4, 3
• Monitor blood pressure at each visit 4, 3
• Consider nephrology referral if hematuria persists with development of hypertension, proteinuria, or evidence of glomerular bleeding 4, 3