What is the appropriate management for a patient with hematuria?

Management of 2-5 RBCs/HPF on Urinalysis

This finding of 2-5 erythrocytes per high-power field falls within the normal to borderline range and does not meet the diagnostic threshold for microscopic hematuria, which requires ≥3 RBCs/HPF on at least two of three properly collected specimens. 1

Diagnostic Threshold and Confirmation

• Microscopic hematuria is defined as ≥3 RBCs/HPF, not 0-2 RBCs/HPF, and the American Urological Association explicitly states that findings below this threshold should not trigger imaging or further urologic investigation without confirmation. 1

• A single finding of 2-5 RBCs/HPF requires confirmation with repeat microscopic urinalysis before any workup is initiated, as the American Academy of Family Physicians recommends confirming microscopic hematuria on at least two of three properly collected clean-catch midstream specimens. 1

• Dipstick positivity alone has limited specificity (65-99%) and can produce false positives from myoglobinuria, hemoglobinuria, or menstrual contamination, so microscopic confirmation is mandatory. 1, 2

Recommended Management Approach

• Document this finding as within normal limits or borderline and do not initiate urologic workup (no cystoscopy, no CT urography) at this time. 1

• Repeat urinalysis in 6 months if there are no concerning symptoms, as patients with <5 RBCs/HPF on three urinalyses are unlikely to have significant pathology and can be followed conservatively. 3

• Ensure the specimen was properly collected (clean-catch midstream) and exclude transient causes such as menstruation, vigorous exercise, or recent viral illness before repeat testing. 4, 1

When to Escalate Evaluation

Immediate re-evaluation with full urologic workup is warranted if any of the following develop:

• Gross (visible) hematuria - this carries a 30-40% risk of malignancy and requires urgent urologic referral regardless of whether bleeding is self-limited. 1, 5, 2

• Repeat urinalysis showing ≥3 RBCs/HPF on microscopic examination - this meets the diagnostic threshold for true microscopic hematuria requiring risk stratification and potential workup. 1, 6

• New urologic symptoms including irritative voiding symptoms (frequency, urgency, dysuria) without infection, flank pain, or suprapubic pain. 1, 5

• High-risk features such as occupational exposure to chemicals/dyes (benzenes, aromatic amines), history of smoking >10 pack-years, or age >60 years in men or women. 1, 5

Critical Pitfalls to Avoid

• Do not attribute borderline findings to anticoagulation or antiplatelet therapy - these medications may unmask underlying pathology but do not cause hematuria themselves, though this principle applies more to confirmed hematuria (≥3 RBCs/HPF). 4, 1, 2

• Do not proceed with cystoscopy or imaging based on dipstick alone - the American Urological Association explicitly warns against imaging without microscopic confirmation of ≥3 RBCs/HPF. 1

• Do not ignore subsequent findings of ≥3 RBCs/HPF - if repeat testing confirms true microscopic hematuria, full risk stratification and evaluation become necessary based on age, smoking history, and degree of hematuria. 1, 5

Risk Stratification If Hematuria Confirmed on Repeat Testing

If subsequent urinalysis shows ≥3 RBCs/HPF, stratify risk as follows:

• Low risk: Women <60 years, men <40 years, never smoker or <10 pack-years, 3-10 RBCs/HPF - may undergo shared decision-making regarding cystoscopy and renal ultrasound versus continued surveillance. 1

• Intermediate risk: Women ≥60 years, men 40-59 years, 10-30 pack-years smoking history - cystoscopy and upper tract imaging (CT urography or renal ultrasound) recommended. 1, 5

• High risk: Men ≥60 years, >30 pack-years smoking history, occupational chemical exposure, history of gross hematuria - mandatory cystoscopy and multiphasic CT urography. 1, 5

Special Considerations for Glomerular Disease

• Assess for proteinuria using spot urine protein-to-creatinine ratio if hematuria is confirmed, as significant proteinuria (>0.2 g/g) with hematuria strongly suggests glomerular disease. 1

• Examine urinary sediment for dysmorphic RBCs (>80%) or red cell casts - these findings are pathognomonic for glomerular disease and warrant nephrology referral rather than urologic evaluation. 1, 5

• Check serum creatinine - elevated creatinine with hematuria suggests renal parenchymal disease requiring nephrology consultation. 1, 5