What further evaluation is needed for a patient with microscopic hematuria (presence of blood in urine) after a negative cystoscopy (visual examination of the bladder using a scope)?

Further Evaluation After Negative Cystoscopy for Microscopic Hematuria

Most patients with microscopic hematuria and a negative cystoscopy do not require ongoing urologic monitoring and can be safely discharged after shared decision-making, though you should first confirm the initial evaluation was complete with upper tract imaging. 1

Confirm Complete Initial Evaluation

Before discharging this patient, verify that a complete risk-stratified hematuria evaluation was performed:

• Upper tract imaging is essential - Cystoscopy alone is insufficient, as it only evaluates the bladder and cannot detect upper urinary tract urothelial carcinoma (UTUC) or renal masses 1
• If upper tract imaging was not performed, obtain CT urography, MR urography, or renal ultrasound based on the patient's risk stratification 1
• Urine cytology and tumor markers should NOT be routinely used after a normal cystoscopy, as they have poor diagnostic yield in this setting 1

Risk Stratification Considerations

The patient's risk category determines whether additional evaluation is warranted:

• Age ≥60 years, >30 pack-year smoking history, or >25 RBCs/HPF places patients in the high-risk category 1
• Personal or family history of Lynch syndrome warrants upper tract imaging regardless of other risk factors 1
• Family history of renal cell carcinoma or genetic renal tumor syndromes (von Hippel-Lindau, Birt-Hogg-Dube, tuberous sclerosis) requires upper tract imaging 1

Follow-Up Recommendations

After a complete negative evaluation (cystoscopy + upper tract imaging), engage in shared decision-making about repeat urinalysis rather than mandating ongoing surveillance: 1

• Repeat UA at future intervals may be considered for select high-risk patients (heavy smoking history, multiple risk factors) who desire follow-up 1
• If repeat UA is negative after the initial negative evaluation, no further hematuria follow-up is needed 1
• The diagnostic yield of repeat evaluation is extremely low - only 1.2% of patients with persistent hematuria after negative workup developed bladder cancer on repeat cystoscopy, and these cancers were detected >36 months later 1, 2

When to Re-Evaluate

Immediate re-evaluation is warranted only if the patient develops: 1

• Gross hematuria (visible blood in urine) 1
• Significant increase in degree of microscopic hematuria 1
• New urologic symptoms (irritative voiding symptoms, dysuria) 1
• Abnormal cytology (if obtained) 1

Key Clinical Pitfalls

• Do not obtain urine cytology routinely - The 2025 AUA/SUFU guidelines explicitly recommend against using cytology or tumor markers as adjunctive tests after normal cystoscopy 1
• Cystoscopy alone is inadequate - Upper tract imaging is required to complete the evaluation, as cystoscopy has high specificity (93-100%) but cannot visualize the upper tracts 1
• Avoid over-surveillance - The malignancy risk after complete negative evaluation is <1%, and most detected cancers occur >3 years later 1, 2
• Consider nephrologic causes - If proteinuria, hypertension, or elevated creatinine develop, refer to nephrology rather than repeating urologic evaluation 3, 4

Practical Discharge Plan

For this specific patient with 25 RBCs on UA and negative cystoscopy:

1. Confirm upper tract imaging was completed - If not, obtain appropriate imaging based on risk factors 1
2. If complete evaluation is negative, discuss discharge from urology with explanation that ongoing monitoring has minimal yield 1
3. Provide return precautions - Instruct patient to return immediately for gross hematuria or new urinary symptoms 1
4. Optional repeat UA - May consider single repeat UA in 6-12 months for high-risk patients who desire reassurance, but this is not mandatory 1, 3