What is the management approach for an asymptomatic elderly male patient with microscopic hematuria (0-2 red blood cells per high power field) in urine?

Management of 0-2 RBCs per HPF in an Asymptomatic Elderly Male

This finding does NOT meet the diagnostic threshold for microscopic hematuria and therefore does not require urologic evaluation. 1, 2

Diagnostic Threshold Not Met

• Microscopic hematuria is defined as ≥3 red blood cells per high-power field (RBC/HPF) on microscopic evaluation, not 0-2 RBCs/HPF 1, 2, 3
• The American Urological Association explicitly states that "a dipstick reading suggestive of hematuria should not lead to imaging or further investigation without confirmation of three or greater red blood cells per high power field" 1
• 0-2 RBCs/HPF falls within the normal range and does not warrant the extensive urologic workup (cystoscopy and CT urography) that would be indicated for true microscopic hematuria in an elderly male 1, 2

Why This Distinction Matters Clinically

• Even though elderly males represent a high-risk population for urologic malignancy (age ≥60 years is a major risk factor), the evaluation algorithm only applies when the diagnostic threshold of ≥3 RBCs/HPF is met 2, 3
• The 2012 AUA guideline specifically designed the ≥3 RBCs/HPF cutoff to balance sensitivity for detecting malignancy against unnecessary testing in patients with normal urinary findings 1
• Research demonstrates that 3-8 RBCs/HPF is the accepted dividing point between normal and abnormal hematuria 4

Recommended Management Approach

For this patient with 0-2 RBCs/HPF:

• No urologic workup is indicated at this time (no cystoscopy, no CT urography) 1, 2
• Document the finding as within normal limits 1
• If there was a positive dipstick that prompted this microscopy, consider it a false positive and do not pursue further hematuria evaluation 2

Important Caveats and When to Reconsider

Repeat urinalysis is warranted if:

• The patient develops gross (visible) hematuria, which always requires urgent urologic evaluation regardless of microscopy results 2
• New urologic symptoms emerge (irritative voiding symptoms, flank pain, dysuria) 1, 3
• A subsequent urinalysis shows ≥3 RBCs/HPF on microscopic examination 1, 2

Consider alternative explanations if dipstick was positive:

• Myoglobinuria from rhabdomyolysis 2
• Hemoglobinuria from hemolysis 2
• Contamination from recent vigorous exercise or sexual activity 2

What Would Trigger Full Evaluation

If this patient had ≥3 RBCs/HPF, then as an elderly male he would be classified as high-risk and require: 2, 3

• Multiphasic CT urography (preferred upper tract imaging) 1, 3
• Cystoscopy (mandatory for bladder evaluation) 1, 3
• Renal function testing 2, 3
• Urine cytology consideration given high-risk status 3

The risk factors that make elderly males high-risk include: 2, 3

• Male gender 3
• Age ≥60 years 3
• Any smoking history (risk increases with pack-years) 3

However, none of this applies to your patient because 0-2 RBCs/HPF is below the diagnostic threshold. 1, 2