What is the next step in managing a patient with microscopic hematuria (RBC 11-20) and normal WBC count (0-3), with all other urinalysis parameters being normal?

Management of Microscopic Hematuria (11-20 RBC/HPF)

For a patient with 11-20 RBC/HPF and normal WBC count, you should proceed with risk stratification and pursue urologic evaluation based on the patient's risk category, as this level of hematuria (11-25 RBC/HPF) places them in at least the intermediate-risk category according to AUA/SUFU guidelines. 1

Initial Confirmation and Exclusion of Benign Causes

Before proceeding with extensive workup, confirm the following:

• Verify this is true microscopic hematuria (≥3 RBC/HPF is the diagnostic threshold) on a properly collected clean-catch midstream specimen 2
• Rule out urinary tract infection by obtaining urine culture; if positive, treat appropriately and repeat urinalysis 6 weeks after treatment completion to confirm resolution 2
• Exclude menstruation in women by repeating urinalysis 48 hours after cessation of menses 2, 3
• Consider recent vigorous exercise and repeat urinalysis 48 hours after cessation if suspected 2

Risk Stratification Based on AUA/SUFU Guidelines

The degree of hematuria (11-20 RBC/HPF) automatically places your patient in the intermediate-risk category (11-25 RBC/HPF) 1, 2. However, additional risk factors will determine the final risk category:

High-Risk Features (require cystoscopy + upper tract imaging):

• Age ≥60 years (men or women) 1, 2
• Smoking history >30 pack-years 1, 2
• History of gross hematuria 1, 2
• Occupational exposure to chemicals/dyes (benzenes, aromatic amines) 2, 4
• History of pelvic irradiation 2

Intermediate-Risk Features (cystoscopy + imaging via shared decision-making):

• Age 50-59 years (women) or 40-59 years (men) 1, 2
• Smoking history 10-30 pack-years 1, 2
• 11-25 RBC/HPF on single urinalysis 1, 2
• Irritative voiding symptoms 2, 4
• History of recurrent UTIs 2

Low-Risk Features:

• Age <50 years (women) or <40 years (men) 1, 2
• Never smoker or <10 pack-years 1, 2
• No additional risk factors for urothelial cancer 1, 2

Recommended Evaluation Based on Risk Category

For High-Risk Patients:

• Cystoscopy (mandatory) - flexible cystoscopy preferred for superior diagnostic accuracy and less discomfort 2, 4
• Multiphasic CT urography - preferred imaging modality for detecting renal cell carcinoma, transitional cell carcinoma, and urolithiasis 2, 4
• Serum creatinine to assess renal function 2, 4
• Voided urine cytology in high-risk patients to detect high-grade urothelial carcinomas 2, 4

For Intermediate-Risk Patients:

• Shared decision-making regarding cystoscopy and urinary tract imaging 1, 2
• Urinary tract ultrasound may be considered as alternative to CT 5
• Assess for glomerular disease indicators: examine urinary sediment for dysmorphic RBCs (>80% suggests glomerular source) and red cell casts 2, 4
• Check for proteinuria - if >500 mg/24 hours, consider nephrology referral 2, 4

For Low-Risk Patients:

• Repeat urinalysis in 6 months OR proceed with evaluation based on patient preference 1, 2
• If hematuria persists on repeat testing, proceed with cystoscopy and imaging 2

Assessment for Glomerular vs. Non-Glomerular Source

Examine urinary sediment for:

• Dysmorphic RBCs - >80% suggests glomerular origin 2, 4
• Red cell casts - pathognomonic for glomerular disease 2, 4
• Significant proteinuria - >500 mg/24 hours suggests renal parenchymal disease 2, 4
• Elevated serum creatinine - indicates potential glomerular involvement 2, 4

If glomerular disease is suspected, refer to nephrology in addition to completing urologic evaluation 2, 4

Follow-Up After Negative Initial Evaluation

If complete workup is negative but hematuria persists:

• Repeat urinalysis at 6,12,24, and 36 months 2, 4
• Monitor blood pressure at each visit 2, 4
• Consider repeat cystoscopy and imaging within 3-5 years for persistent or recurrent hematuria, particularly in high-risk populations 2

Immediate Re-Evaluation Required If:

• Gross hematuria develops 1, 2
• Significant increase in degree of microscopic hematuria 1, 2
• New urologic symptoms appear 1, 2
• Development of hypertension, proteinuria, or evidence of glomerular bleeding 2, 4

Critical Pitfalls to Avoid

• Do not attribute hematuria to anticoagulation or antiplatelet therapy - these medications may unmask underlying pathology but do not cause hematuria themselves; evaluation should proceed regardless 2, 4
• Do not delay evaluation in patients with rapid recurrence of UTI with the same organism, as this may warrant imaging to rule out calculus 2
• Do not assume benign cause without proper verification - even if a potential benign cause is identified, persistent hematuria requires appropriate risk-based evaluation 1, 2
• Do not rely solely on dipstick results - confirm with microscopic examination showing ≥3 RBC/HPF 2, 4