What's the next step for a woman in her 50s with hematuria (presence of blood in urine), moderate occult blood, trace leukocyte esterase, and 6-10 red blood cells (RBCs) in her urinalysis results?

Next Steps for Hematuria in a Woman in Her 50s

This patient requires confirmation with microscopic urinalysis before any urologic workup is initiated, and if confirmed with ≥3 RBCs/HPF on repeat testing, she should undergo complete urologic evaluation with cystoscopy and upper tract imaging given her intermediate-risk status. 1, 2

Immediate Action: Confirm True Hematuria

• The dipstick finding of "moderate occult blood" must be confirmed with microscopic urinalysis showing ≥3 RBCs per high-power field before proceeding with any further evaluation. 2, 3
• Dipstick tests have only 65-99% specificity and can produce false-positive results from myoglobin, hemoglobin, or menstrual contamination. 2, 4
• The urinalysis shows 6-10 RBCs/HPF on microscopy, which confirms true microhematuria and warrants further evaluation. 1, 2
• Ensure the specimen was a clean-catch midstream collection to exclude vaginal contamination, particularly given the trace leukocyte esterase. 2, 4

Risk Stratification Based on Updated 2025 Guidelines

According to the 2025 AUA/SUFU guidelines, this patient falls into the LOW-RISK category because: 1

• She is a woman under age 60 (the threshold was recently changed from <50 to <60 years for women). 1
• She has 6-10 RBCs/HPF (low-grade microhematuria, defined as 3-10 RBCs/HPF). 1
• Women should not be categorized as high-risk based on age alone and require additional risk factors to move into higher risk categories. 1

However, you must assess for additional risk factors that would elevate her risk category: 1, 2

• Smoking history (>10 pack-years moves to intermediate risk; >30 pack-years to high risk). 1
• History of gross hematuria (automatically high-risk regardless of other factors). 2
• Occupational exposure to chemicals/dyes (benzenes, aromatic amines). 2
• Irritative voiding symptoms without infection (high-risk feature). 2
• History of pelvic radiation or cyclophosphamide exposure. 1

Management Algorithm Based on Risk Category

If She Remains Low-Risk (No Additional Risk Factors):

• Repeat urinalysis to confirm persistence of microhematuria. 1
• If repeat UA shows no evidence of microhematuria (0-2 RBCs/HPF), no further evaluation of bladder or upper tract is needed at this time. 1
• If microhematuria persists at similar level (3-10 RBCs/HPF), further evaluation may be considered through shared decision-making, but is not mandatory for low-risk patients. 1
• The 2025 guidelines acknowledge that women under 60 have very low risk of malignancy in the absence of other risk factors. 1

If She Has ANY Additional Risk Factors (Intermediate or High-Risk):

Complete urologic evaluation is mandatory and includes: 1, 2

1. Upper tract imaging with multiphasic CT urography (preferred modality for detecting renal cell carcinoma, transitional cell carcinoma, and urolithiasis). 2

   • Almost 70% of malignancies in hematuria patients are found in the kidney, underscoring the importance of upper tract imaging. 1
   • If CT is contraindicated (renal insufficiency, contrast allergy), consider MR urography or renal ultrasound with retrograde pyelography. 2

2. Cystoscopy (mandatory for intermediate- and high-risk patients to evaluate for bladder cancer). 1, 2

   • Flexible cystoscopy is preferred as it causes less pain with equivalent diagnostic accuracy. 2

3. Laboratory evaluation:

   • Serum creatinine and BUN to assess renal function. 2
   • Urine culture if infection suspected (given trace leukocyte esterase). 2
   • Do NOT obtain urine cytology in the initial evaluation—it is not recommended by current guidelines. 2

Addressing the Trace Leukocyte Esterase

• The trace leukocyte esterase finding requires consideration of urinary tract infection. 2
• If the patient has dysuria, frequency, or urgency, obtain urine culture before starting antibiotics. 2
• If she is completely asymptomatic, this likely represents sterile pyuria or contamination and does not require antibiotics. 2
• Do not treat asymptomatic bacteriuria—there is no benefit and high-quality evidence of harm including antibiotic resistance. 2

Critical Pitfalls to Avoid

• Never attribute hematuria to anticoagulation or antiplatelet therapy alone—these medications may unmask underlying pathology but do not cause hematuria themselves. 2
• Do not delay evaluation by prescribing empiric antibiotics without culture confirmation of infection, as this can delay cancer diagnosis. 2
• Do not ignore even low-grade microhematuria in the presence of risk factors—the risk stratification system exists precisely to identify which patients need evaluation. 1
• Menstruation can contaminate specimens; if timing is uncertain, repeat the urinalysis mid-cycle. 2

Follow-Up Protocol if Initial Workup is Negative

If complete evaluation reveals no cause: 2

• Repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring at each visit. 2
• Immediate re-evaluation is warranted if: gross hematuria develops, significant increase in microhematuria occurs, new urologic symptoms appear, or development of hypertension/proteinuria. 2
• Consider nephrology referral if hematuria persists with proteinuria, hypertension, or evidence of glomerular bleeding (dysmorphic RBCs, red cell casts). 2