Urinalysis with 152 Red Blood Cells per High-Power Field
A finding of 152 RBCs/HPF represents severe microscopic hematuria that far exceeds the diagnostic threshold of ≥3 RBCs/HPF and requires immediate complete urologic evaluation including upper tract imaging and cystoscopy, regardless of symptoms. 1
What This Result Means
This is clinically significant hematuria - The threshold for microscopic hematuria is ≥3 RBCs/HPF, and your result of 152 RBCs/HPF is approximately 50 times higher than this diagnostic cutoff 1
This degree of hematuria has substantial malignancy risk - Studies show that patients with ≥5 RBCs/HPF have significantly higher rates of genitourinary tumors and stones, with all patients with genitourinary tumors having either gross hematuria or ≥5 RBCs/HPF 2
The severity suggests active bleeding - While technically "microscopic" (not visible to naked eye), this level approaches what might be considered near-gross hematuria and indicates substantial blood loss into the urinary tract 2
Immediate Next Steps Required
You need urgent urologic evaluation - do not delay or simply repeat the test. 1
Required Workup Components:
Upper tract imaging with CT urography (preferred) or multiphasic CT to evaluate kidneys and ureters for malignancy, stones, or structural abnormalities 3, 4
Cystoscopy to directly visualize the bladder for tumors, inflammation, or other pathology - this is mandatory regardless of age given the severity of hematuria 3, 4
Comprehensive urinalysis with sediment examination to assess for:
Serum creatinine to assess kidney function 4
Urine cytology to screen for transitional cell carcinoma, particularly if you have risk factors 4
Risk Factors That Increase Urgency
The following factors make malignancy more likely and demand even more urgent evaluation 1:
- Age >40 years (especially >60 years) 1, 3
- Male gender 3
- Smoking history (especially >30 pack-years) 1, 3
- Occupational exposure to chemicals/dyes (benzenes, aromatic amines) 1
- History of gross (visible) hematuria 1
- Irritative voiding symptoms 1
- History of pelvic irradiation 1
- Analgesic abuse 1
Potential Causes to Consider
Urologic Causes (Most Common):
- Malignancy - bladder cancer, kidney cancer, or prostate cancer accounts for 30-40% of gross hematuria cases and 2.6-4% of microscopic hematuria cases 3
- Urolithiasis - kidney or ureteral stones 3
- Urinary tract infection 3
- Benign prostatic hyperplasia (in men) 3
- Trauma to kidneys or lower urinary tract 3
Renal/Glomerular Causes:
- Glomerulonephritis (post-infectious, IgA nephropathy) 3
- Alport syndrome 3
- Thin basement membrane nephropathy 3
Other Causes:
Critical Clinical Pitfalls to Avoid
Do NOT attribute this to anticoagulation or antiplatelet therapy alone - these medications may unmask underlying pathology but do not cause hematuria; full evaluation is still required 1, 3
Do NOT simply repeat the urinalysis and wait - this degree of hematuria demands immediate workup, not watchful waiting 1
Do NOT assume infection explains everything - even if UTI is present, hematuria of this magnitude requires full urologic evaluation after infection treatment 3
Do NOT defer evaluation in women - women have historically received incomplete evaluations despite having higher case-fatality rates for bladder cancer 6