What is the next step in evaluating an elderly female patient with microscopic hematuria and a negative urinalysis (UA) with culture?

Evaluation of Trace Blood in Urine in an Elderly Female with Negative UA and Culture

Repeat the urinalysis in 6 weeks to confirm resolution or persistence of microscopic hematuria, and if hematuria persists, proceed with risk-stratified evaluation based on the 2025 AUA/SUFU guidelines. 1

Confirm True Microscopic Hematuria

• The initial step is to verify that "trace blood" represents true microscopic hematuria, defined as ≥3 red blood cells per high-power field (RBC/HPF) on microscopic examination, not just a positive dipstick result 2
• Dipstick testing has limited specificity (65-99%) and must always be confirmed with microscopic urinalysis 3
• If microscopic examination was not performed initially, obtain it now before proceeding with further evaluation 2

Rule Out Benign Causes

• Since the urine culture is negative, urinary tract infection has been excluded 2
• Confirm the patient is not menstruating, has not had recent vigorous exercise, sexual activity, or trauma—all of which can cause transient hematuria 2, 3
• If a benign cause is identified, repeat urinalysis 48 hours after cessation of the potential cause 2

Risk Stratification Using 2025 Updated Criteria

The 2025 AUA/SUFU guidelines significantly revised risk categories for women based on validation studies showing very low malignancy risk in younger women 1:

Low-Risk Category:

• Women age <60 years (updated from <50 years in 2020 guidelines) 1
• Never smoker or <10 pack-years 1
• 3-10 RBC/HPF on urinalysis 1
• No additional risk factors for urothelial cancer 1

Intermediate-Risk Category:

• Women age ≥60 years (updated from 50-59 years) 1
• 10-30 pack-years smoking history 1
• 11-25 RBC/HPF on urinalysis 1

High-Risk Category:

• Women should NOT be categorized as high-risk based on age alone—this is a critical 2025 update 1
• High-risk designation requires one or more of: >30 pack-years smoking history, >25 RBC/HPF, history of gross hematuria, or occupational exposure to chemicals (benzenes, aromatic amines) 1, 2

Risk-Based Evaluation Algorithm

For Low-Risk Patients:

• Repeat urinalysis in 6 months 1, 2
• If repeat UA shows no hematuria (negative), discharge from further hematuria evaluation 1
• If hematuria persists (3-10 RBC/HPF), engage in shared decision-making about proceeding with cystoscopy and urinary tract imaging versus continued observation 1
• Validation studies showed 0% cancer detection in the low-risk group 1

For Intermediate-Risk Patients:

• Cystoscopy with urinary tract imaging (CT urography preferred, or renal ultrasound) through shared decision-making 1, 2
• Cancer detection rate is approximately 3.1% in this group 1
• Among women age 60+, most malignancies (approximately 70%) were found in the upper tract, emphasizing the importance of imaging 1

For High-Risk Patients:

• Mandatory cystoscopy and upper tract imaging (multiphasic CT urography preferred) 1, 3
• Cancer detection rate is approximately 6.3% in this group 1
• Among high-risk patients with gross hematuria history, cancer incidence reaches 10.9% 1

Assess for Glomerular Disease

• Examine urinary sediment for dysmorphic red blood cells (>80% suggests glomerular source) and red cell casts 2, 3
• Check for significant proteinuria (>500 mg/24 hours) and measure serum creatinine 2, 3
• If glomerular indicators are present (dysmorphic RBCs, red cell casts, significant proteinuria, or elevated creatinine), refer to nephrology in addition to completing urologic evaluation 2, 3

Critical Pitfalls to Avoid

• Do not attribute hematuria solely to anticoagulation or antiplatelet therapy—these patients require the same evaluation as non-anticoagulated patients 2
• Do not rely on dipstick alone—microscopic confirmation is mandatory 2, 3
• Do not skip upper tract imaging if urologic evaluation is indicated—cystoscopy alone misses upper tract malignancies, which comprised 70% of cancers detected in elderly women in validation studies 1, 4
• Do not automatically discharge elderly women without evaluation—while the 2025 guidelines lowered risk stratification for younger women, validation studies found that 11 of 13 malignancies in women occurred in those over age 60 1

Follow-Up After Negative Evaluation

• If complete evaluation (cystoscopy + upper tract imaging) is negative but hematuria persists, repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring 1, 2
• Immediate re-evaluation is warranted if gross hematuria develops, significant increase in degree of microscopic hematuria occurs, or new urologic symptoms appear 1, 4
• After a negative repeat UA following initial negative evaluation, no further hematuria follow-up is needed 4