What is the urgency of evaluating amorphous crystals and hematuria (presence of Red Blood Cells (RBC)) in urine with symptoms of urinary frequency, but no dysuria, for 2 months?

From the Guidelines

A retroperitoneal ultrasound for a patient with amorphous crystals and RBCs on urinalysis with only urinary frequency (no dysuria) for two months does not require a stat (emergency) order. This can be scheduled as a routine study within the next few weeks. The presence of amorphous crystals is common and often clinically insignificant, while microscopic hematuria without pain or other concerning symptoms typically doesn't indicate an urgent condition requiring immediate imaging, as noted in the guidelines for evaluating hematuria 1. However, the ultrasound should still be performed to evaluate for potential causes such as kidney stones, urinary tract infections, or less commonly, tumors.

While waiting for the ultrasound, it's reasonable to:

• Obtain a urine culture to rule out infection
• Recommend increased fluid intake (2-3 liters daily)
• Consider symptomatic treatment for frequency with an anticholinergic medication like oxybutynin 5mg twice daily if appropriate If the patient develops new symptoms like severe pain, gross hematuria, fever, or signs of urinary obstruction, the imaging should be expedited. The American Urological Association's best practice policy recommendations also suggest that cystoscopic evaluation of the bladder is necessary to exclude the presence of bladder cancer, especially in patients over 40 years of age or those with risk factors for bladder cancer 1.

From the Research

Hematuria Evaluation

• Hematuria is a common condition that can be classified as either gross or microscopic, and it warrants a thorough history and physical to determine potential causes and assess risk factors for malignancy 2.
• The risk of malignancy with gross hematuria is greater than 10%, and prompt urologic referral is recommended, whereas microscopic hematuria most commonly has benign causes, such as urinary tract infection, benign prostatic hyperplasia, and urinary calculi 2.

Imaging Modalities

• Ultrasonography is an appropriate modality for upper tract imaging in the initial evaluation of patients with asymptomatic microscopic hematuria, with a sensitivity of 100% for detecting renal cell carcinoma and upper tract urothelial cancer 3.
• Computed tomography (CT) scans are also effective in evaluating hematuria, particularly in patients over 40, and can be used to detect kidney stones and other abnormalities 4.
• Non-contrast CT scans are considered the gold standard for evaluating urolithiasis, and hematuria has a sensitivity of 77% and specificity of 33% for diagnosing renal and ureteral stones 5.

Clinical Considerations

• The presence of microscopic hematuria does not necessarily indicate a urgent condition, but it does require further evaluation to rule out underlying causes such as kidney stones, urinary tract infections, or malignancy 2, 3, 4.
• In patients with microscopic hematuria and no benign cause, a non-contrast CT scan or ultrasound study should be performed to evaluate for upper tract malignancy and other abnormalities 3, 4.
• The absence of dysuria and the presence of frequency for 2 months may suggest a non-urgent condition, but further evaluation is still necessary to determine the underlying cause of hematuria 2, 6.