What is the best management approach for a young or middle-aged patient with low-risk hematuria and no significant medical history?

Management of Low-Risk Hematuria

For young or middle-aged patients with low-risk hematuria (age <60 years for women or <40 years for men, <10 pack-years smoking, 3-10 RBC/HPF, no additional risk factors), repeat urinalysis in 6 months and engage in shared decision-making about proceeding with cystoscopy and imaging only if hematuria persists—most can be safely observed without immediate invasive evaluation. 1

Confirming True Microscopic Hematuria

Before initiating any workup, you must confirm true microscopic hematuria with microscopic examination showing ≥3 red blood cells per high-power field (RBC/HPF). 2, 1

• Dipstick testing alone is insufficient with specificity of only 65-99% and can yield false positives from myoglobinuria, hemoglobinuria, menstruation, or concentrated urine. 2, 1
• Always obtain microscopic confirmation before causing patient anxiety or initiating costly evaluations. 1

Risk Stratification Criteria

The 2025 AUA/SUFU guidelines define low-risk patients as those meeting ALL of the following criteria: 1

• Age: Women <60 years OR men <40 years 1
• Smoking history: Never smoker OR <10 pack-years 1
• Degree of hematuria: 3-10 RBC/HPF on single urinalysis 1
• No additional risk factors for urothelial cancer (no history of gross hematuria, no occupational exposure to benzenes/aromatic amines, no history of pelvic irradiation, no chronic indwelling foreign body) 1

If your patient fails to meet even one of these criteria, they are NOT low-risk and require more intensive evaluation.

Initial Clinical Assessment

Perform a focused evaluation looking specifically for: 1

• Blood pressure measurement (hypertension suggests glomerular disease) 1
• Serum creatinine (elevated suggests nephropathy) 1
• Detailed smoking history (quantify pack-years precisely) 1
• Occupational/environmental exposures (dyes, chemicals, rubber, leather industries) 1
• Family history of urologic malignancies or hereditary kidney disease 1
• Medication review (cyclophosphamide, analgesic abuse) 1

Rule Out Benign Transient Causes

Before proceeding with risk stratification, exclude: 3

• Urinary tract infection: Obtain urine culture; if positive, treat and repeat urinalysis 6 weeks after treatment completion 3
• Menstruation: Repeat urinalysis 48 hours after cessation 3
• Vigorous exercise: Repeat urinalysis 48 hours after rest 3
• Recent sexual activity or trauma 3

Assess for Glomerular Disease

Examine the urinary sediment for: 2, 1

• Dysmorphic red blood cells (>80% suggests glomerular source) 2
• Red cell casts (pathognomonic for glomerular disease) 2
• Significant proteinuria (>500 mg/24 hours warrants nephrology referral) 3

If glomerular disease is suspected, refer to nephrology in addition to completing urologic evaluation if hematuria persists. 3

Management Algorithm for Confirmed Low-Risk Patients

If All Low-Risk Criteria Are Met:

Step 1: Observation with repeat urinalysis in 6 months 1

The malignancy risk in true low-risk patients is extremely low (0-0.4%), justifying conservative management. 1 Most patients who have an appropriate risk-stratified negative hematuria evaluation do not require ongoing urologic monitoring and may be safely discharged after shared decision-making. 4

Step 2: If hematuria resolves (negative repeat UA):

• No further hematuria-specific follow-up is needed 4
• Patient can be discharged from urologic care 4

Step 3: If hematuria persists (≥3 RBC/HPF) at 6 months:

Engage in shared decision-making regarding proceeding with cystoscopy and urinary tract imaging. 1 While risk remains low, persistent hematuria warrants consideration of complete evaluation based on: 1

• Patient preference and anxiety level
• Clinical judgment
• Presence of any evolving risk factors

If Patient and Clinician Opt for Continued Observation:

Implement long-term monitoring with: 1

• Repeat urinalysis at 6,12,24, and 36 months 1
• Blood pressure monitoring at each visit 1
• Consider repeat complete evaluation within 3-5 years if hematuria persists and patient has any risk factors 1

Critical Pitfalls to Avoid

Do Not Attribute Hematuria to Anticoagulation

Patients on anticoagulation or antiplatelet therapy require the same evaluation as non-anticoagulated patients. 1 Anticoagulation does not cause hematuria—it merely unmasks underlying pathology. The malignancy risk is similar regardless of anticoagulation status. 3

Do Not Delay Evaluation for Changing Clinical Status

Immediate re-evaluation is mandatory if: 1

• Gross hematuria develops (odds ratio 7.2 for malignancy) 3
• Significant increase in degree of microscopic hematuria occurs 1
• New urologic symptoms appear (irritative voiding, flank pain, weight loss) 1

These changes override the low-risk designation and require prompt urologic referral. 1

Do Not Skip Microscopic Confirmation

Never initiate workup based on dipstick alone—this leads to unnecessary evaluations and patient anxiety. 1 Always confirm with microscopic examination showing ≥3 RBC/HPF. 2

When to Escalate to Full Urologic Evaluation

Even in initially low-risk patients, proceed with cystoscopy and upper tract imaging if: 1

• Hematuria persists at 6 months AND patient/clinician prefer definitive evaluation through shared decision-making 1
• Any risk factor develops (new smoking history, occupational exposure, age progression into intermediate-risk category) 1
• Degree of hematuria increases to >10 RBC/HPF 1
• Gross hematuria occurs 1

Evidence Quality and Nuances

The 2025 AUA/SUFU guidelines acknowledge that most recommendations are Grade C evidence (expert opinion/observational studies), reflecting the challenge of studying a condition with low malignancy rates. 4 However, the risk stratification system has been validated to separate patients into clinically meaningful categories justifying graduated intensity of evaluation. 4

The key insight is that after a negative MH evaluation and in the absence of a change in clinical condition, repeated evaluation has minimal diagnostic yield. 4 In one study, repeat cystoscopy in 161 patients with negative evaluation and persistent hematuria revealed only 2 new bladder cancers (1.2%), and these were detected more than 36 months after initial evaluation. 4

This evidence supports the conservative approach for true low-risk patients, balancing the small risk of false-negative evaluation against the anxiety, cost, inconvenience, and risks of ongoing monitoring. 4