What is the recommended evaluation and management for hematuria in a 32-year-old female?

Evaluation and Management of Hematuria in a 32-Year-Old Female

A 32-year-old female with hematuria should first have microscopic urinalysis to confirm ≥3 RBCs/HPF, exclude benign causes (menstruation, UTI, exercise), and then undergo risk stratification using the 2025 AUA/SUFU criteria—she would be classified as low/negligible risk based on age alone (<60 years) if she has 3-10 RBCs/HPF, is a never smoker or has <10 pack-years, and lacks additional risk factors. 1

Initial Confirmation and Exclusion of Benign Causes

• Confirm true hematuria with microscopic urinalysis showing ≥3 RBCs/HPF rather than relying on dipstick alone, which has limited specificity (65-99%) and yields false positives from myoglobinuria, hemoglobinuria, or menstrual contamination. 2

• Exclude transient benign causes before extensive workup, including menstruation, vigorous exercise, sexual activity, viral illness, trauma, and urinary tract infection. 2, 3

• If UTI is suspected, obtain urine culture before starting antibiotics, treat appropriately, then repeat urinalysis 6 weeks after treatment completion to confirm resolution of hematuria—this is a critical safety checkpoint as approximately 3% of patients with microscopic hematuria harbor genitourinary malignancy. 2, 3

• Repeat urinalysis 48 hours after cessation of potential benign causes (menstruation, exercise) if initially suspected. 3

Comprehensive Initial Assessment

Perform a focused history, physical examination, and laboratory evaluation: 1

• Detailed smoking history quantified as pack-years, as this is the strongest modifiable risk factor for urothelial malignancy. 1, 4

• Age and sex are critical stratification factors—women <60 years have significantly lower risk of urothelial malignancy compared to men. 1

• Occupational exposures to benzenes, aromatic amines, or other chemical carcinogens (dyes, rubber, leather industries). 1, 3

• History of gross hematuria, even if not currently present, elevates risk substantially. 1, 3

• Irritative voiding symptoms (urgency, frequency, dysuria, nocturia) may indicate bladder pathology or interstitial cystitis. 1, 4

• Family history of urologic malignancies and genetic risk factors. 1

• Physical examination including blood pressure measurement to assess for renal parenchymal disease. 1, 2

• Serum creatinine to evaluate renal function. 1, 2

Risk Stratification Using 2025 AUA/SUFU Criteria

The 2025 guidelines provide updated risk categories with significantly revised age thresholds for women: 1

Low/Negligible Risk (0-0.4% malignancy risk)

Patient must meet ALL of the following: 1

• Age <60 years for women (updated from <50 years in 2020 guidelines)
• Never smoker or <10 pack-years
• 3-10 RBCs/HPF on single urinalysis
• No additional risk factors for urothelial cancer

Intermediate Risk (0.2-3.1% malignancy risk)

Patient meets ONE OR MORE of: 1

• Age ≥60 years for women
• 10-30 pack-years smoking history
• 11-25 RBCs/HPF on single urinalysis
• Any additional risk factors for urothelial cancer

High Risk (1.3-6.3% malignancy risk)

Patient meets ONE OR MORE of: 1

• 30 pack-years smoking history

• 25 RBCs/HPF on single urinalysis

• History of gross hematuria with no prior evaluation
• Multiple high-risk features combined

Critical update: Women cannot be categorized as high-risk based on age alone in the 2025 guidelines, reflecting interval studies showing significantly lower risk of urothelial malignancy in women. 1

Distinguishing Glomerular from Non-Glomerular Sources

Before proceeding with urologic evaluation, assess for glomerular disease: 2, 3

• Dysmorphic RBCs >80% on urinary sediment examination suggests glomerular source. 2, 3

• Red blood cell casts are pathognomonic for glomerular bleeding. 2, 3

• Significant proteinuria >500 mg/24 hours indicates potential glomerular disease. 2, 3

• Elevated serum creatinine or associated hypertension suggests renal parenchymal disease. 2, 3

Refer to nephrology if proteinuria >1,000 mg/24 hours, dysmorphic RBCs >80% with red cell casts, elevated creatinine, or associated hypertension—however, risk-based urologic evaluation should still be performed as coexistent urologic pathology may exist. 1, 2, 3

Management Based on Risk Category

For Low/Negligible Risk Patients (Most Likely Category for This 32-Year-Old)

• Shared decision-making regarding immediate evaluation versus surveillance. 1

• Option 1: Repeat urinalysis in 6 months; if hematuria persists, reclassify as intermediate-risk and proceed with cystoscopy and renal ultrasound. 1

• Option 2: Proceed directly with cystoscopy and renal ultrasound based on patient preference and anxiety level. 1

For Intermediate Risk Patients

• Cystoscopy with urinary tract imaging through shared decision-making. 3

• Renal ultrasound is appropriate for intermediate-risk patients rather than CT urography. 1

For High Risk Patients

• Mandatory cystoscopy to detect bladder tumors and carcinoma in situ. 2, 3

• Multiphasic CT urography as the preferred upper tract imaging modality. 1, 2

• Urine cytology in high-risk patients to detect urothelial cancers. 2

Critical Pitfalls to Avoid

• Never attribute hematuria solely to anticoagulation or antiplatelet therapy—these medications may unmask underlying pathology but do not cause hematuria themselves; patients on anticoagulation should be evaluated identically to non-anticoagulated patients. 2, 3

• Do not delay evaluation in patients with rapid recurrence of UTI with the same organism, as this may indicate calculus disease, particularly with struvite stone-forming bacteria like P. mirabilis. 2, 3

• Avoid relying on dipstick alone without microscopic confirmation. 2

• Do not use urine markers (NMP22, BTA stat, ImmunoCyt, UroVysion FISH) for initial evaluation of asymptomatic microscopic hematuria—these miss 18-43% of bladder cancers and give false-positives in 12-26% of patients without cancer. 1

• Routine urine cytology is no longer recommended in the initial evaluation of asymptomatic microscopic hematuria. 1

Follow-Up for Persistent Hematuria After Negative Evaluation

If initial evaluation is negative but hematuria persists: 2, 3

• Repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring at each visit. 2, 3

• Consider comprehensive re-evaluation in 3-5 years if hematuria persists or recurs, particularly if risk factors develop. 2, 3

• Immediate re-evaluation warranted if gross hematuria develops, significant increase in degree of microscopic hematuria occurs, or new urologic symptoms appear. 3

• Nephrology referral if hematuria persists with development of hypertension, proteinuria, or evidence of glomerular bleeding. 3

Practical Algorithm for This 32-Year-Old Female

1. Confirm microscopic hematuria (≥3 RBCs/HPF) and exclude menstruation, recent exercise, sexual activity
2. Obtain urine culture; if positive, treat and recheck UA in 6 weeks
3. Assess for glomerular disease (dysmorphic RBCs, casts, proteinuria, elevated creatinine)
4. Risk stratify using 2025 AUA/SUFU criteria—likely low/negligible risk if age <60, never smoker/<10 pack-years, 3-10 RBCs/HPF, no additional risk factors
5. If low-risk: Shared decision-making for either repeat UA in 6 months versus proceeding with cystoscopy and renal ultrasound
6. If intermediate/high-risk (unlikely at age 32 unless significant smoking history or other risk factors): Proceed with cystoscopy and appropriate imaging