What are the next steps in management for a patient with normal scan and urine routine results?

Management of Normal Scan and Urine Routine Results

In patients with normal imaging and normal urinalysis, no further urologic surveillance or testing is required unless new symptoms develop or the patient has specific risk factors warranting ongoing monitoring. 1

Immediate Management Recommendations

Discharge from Urologic Care

• Most patients with a negative risk-stratified evaluation and normal studies can be safely discharged from urology practice after shared decision-making. 1
• After a negative hematuria evaluation (which includes normal imaging and urinalysis) and in the absence of clinical changes such as gross hematuria or new symptoms, repeated evaluation has minimal diagnostic yield. 1

Patient Education Requirements

• Educate patients on warning signs that would warrant reassessment, including: 1
  • New or worsening urinary incontinence
  • New or more frequent urinary tract infections, especially with fever or flank pain
  • Any visible blood in urine (gross hematuria)
  • New difficulties with urination or catheterization
  • Development of flank pain or upper tract symptoms

Risk-Stratified Follow-Up Approach

Low-Risk Patients (No Neurogenic Bladder, No Risk Factors)

• Do not obtain surveillance upper tract imaging, renal function assessment, or urodynamics. 1
• Complications would present symptomatically if they develop, allowing for evaluation as clinically indicated. 1
• No routine repeat urinalysis is needed. 1

Patients with Select Risk Factors

The 2025 AUA/SUFU guidelines acknowledge that select patients with multiple risk factors (such as heavy smoking history) may benefit from or request follow-up after a negative evaluation. 1

For these higher-risk patients desiring ongoing surveillance:

• A future urinalysis may be considered through shared decision-making. 1
• The timing and frequency should be individualized based on specific risk factors present.
• Patients who have a negative repeat urinalysis after a negative evaluation do not need further microhematuria follow-up. 1

When to Repeat Urinalysis

Indications for Repeat Testing

• Presence of gross hematuria (visible blood) - this has a substantially stronger association with cancer and requires immediate re-evaluation. 1
• New or worsening urologic symptoms including dysuria, frequency, urgency, or flank pain. 1
• Higher degree of microhematuria on subsequent testing (if urinalysis is repeated for clinical reasons). 1

Timing Considerations

• If infection was initially suspected and treated, repeat urinalysis after treatment to document resolution. 1
• If menstruation, viral illness, or vigorous exercise was suspected as a benign cause, repeat after the cause is excluded. 1
• Some organizations recommend up to 3 repeated analyses in scenarios where transient causes are suspected, though this should be based on the clinical presentation and risk profile. 1

Common Pitfalls to Avoid

Inappropriate Routine Testing

• Routine urinalysis in asymptomatic patients without clinical indication has questionable utility and is not recommended. 2, 3
• Studies show that 40-60% of urinalysis testing in the United States is performed without an appropriate diagnosis code, leading to unnecessary evaluations and costs. 3
• In medical outpatient settings, routine urinalysis led to a change in management in only 0.7% of cases. 2

Overinterpretation of Asymptomatic Findings

• Do not treat asymptomatic bacteriuria - this is common, particularly in older women, and should not receive antibiotics. 4
• Pyuria without symptoms does not indicate infection and is commonly found in the absence of infection, particularly in older adults with lower urinary tract symptoms. 4

Failure to Recognize Warning Signs

• Gross hematuria, even if self-limited, requires evaluation and should not be dismissed. 1
• In one study, 19.8% of patients referred for asymptomatic microhematuria reported a history of visible hematuria when specifically queried, which was significantly underreported. 1

Documentation and Counseling

Key elements to document:

• Discussion of negative findings and their significance
• Warning signs reviewed with patient
• Shared decision-making regarding future surveillance (if applicable)
• Patient understanding of when to seek re-evaluation

Discharge instructions should emphasize:

• Return immediately for any visible blood in urine 1
• Report new urinary symptoms promptly 1
• No routine follow-up urinalysis is needed unless symptoms develop 1