From the Guidelines
For a 30-year-old female with persistent microscopic hematuria and leukocytes in urine, a comprehensive evaluation should begin with a detailed history and physical examination, followed by specific diagnostic tests, prioritizing the most recent and highest quality study available 1.
Initial Evaluation
The initial evaluation should include a repeat urinalysis to confirm findings, urine culture to rule out infection, and a urine cytology to screen for malignancy. Laboratory tests should include serum creatinine, BUN, and complete blood count.
- Repeat urinalysis to confirm microscopic hematuria
- Urine culture to rule out infection
- Urine cytology to screen for malignancy
- Serum creatinine, BUN, and complete blood count
Imaging Studies
Imaging studies are essential, beginning with a renal ultrasound to evaluate for structural abnormalities, stones, or masses.
- Renal ultrasound as the initial imaging study
- Consider multiphase computed tomography (CT) urography if ultrasound is inconclusive or if patient is at high risk for urinary tract cancer
Further Evaluation
If initial workup is inconclusive, consider cystoscopy to directly visualize the bladder and urethra, especially if symptoms persist beyond 4-6 weeks. For recurrent or persistent cases without clear etiology, referral to a urologist or nephrologist is warranted.
- Cystoscopy if initial workup is inconclusive or if symptoms persist
- Referral to a urologist or nephrologist for recurrent or persistent cases
Common Causes
Common causes to consider include urinary tract infection, kidney stones, interstitial cystitis, glomerulonephritis, or less commonly in this age group, malignancy.
- Urinary tract infection
- Kidney stones
- Interstitial cystitis
- Glomerulonephritis
- Malignancy (less common in this age group)
From the Research
Workup of Persistent Microscopic Hematuria and Leukocytes in Urine
- The workup of persistent microscopic hematuria in a 30-year-old female should follow a structured approach, considering risk factors and guidelines to prevent unnecessary procedures and imaging 2.
- The presence of leukocytes in the urine may indicate a urinary tract infection (UTI), and the workup should include an assessment for UTI, as well as other potential causes of hematuria 3, 4.
- The patient's symptoms, medical history, and physical examination findings should be taken into account when determining the appropriate workup and treatment plan 3, 4.
- Urine dipstick analysis and urine culture and sensitivity testing may be useful in diagnosing UTI and guiding antibiotic treatment 3, 5.
- Imaging studies, such as intravenous urography, computed tomography, or ultrasonography, may be necessary to evaluate the upper and lower urinary tract for potential causes of hematuria 4.
- Cystoscopy may be indicated if urine cytology results are abnormal or if hematuria persists after treatment of UTI 4.
Considerations for Antibiotic Treatment
- The choice of antibiotic for UTI treatment should be guided by local resistance patterns and patient-specific risk factors 5.
- Trimethoprim/sulfamethoxazole (SXT) is an effective treatment for UTI, but its use may be associated with an increased risk of adverse outcomes, such as acute kidney injury and hyperkalaemia, particularly in older patients or those with certain comorbidities 6.
- Other antibiotics, such as amoxicillin, cefalexin, or nitrofurantoin, may be alternative treatment options for UTI, depending on the patient's specific needs and local resistance patterns 3, 6.