What is the best course of action for a female patient with a history of microscopic hematuria (presence of blood in urine) and vaginal bleeding, who now has a negative Urinalysis (UA) result, to determine the underlying cause of her symptoms?

Repeat Urinalysis After Gynecologic Bleeding Resolution

You should repeat a quantitative urinalysis (with microscopy) 6 weeks after the vaginal bleeding has resolved to confirm whether the microscopic hematuria has truly cleared. 1, 2, 3

Why This Matters

The AUA/SUFU guidelines explicitly state that when a gynecologic source of microscopic hematuria is identified, clinicians must repeat urinalysis following resolution of that gynecologic cause to confirm the hematuria has resolved. 1 If microscopic hematuria persists after the gynecologic issue resolves, you must proceed with risk-based urologic evaluation. 1, 2

This is critical because:

• Approximately 3% of patients with microscopic hematuria harbor genitourinary malignancy, and this risk increases substantially with specific risk factors 3
• The 6-week repeat urinalysis serves as a critical safety checkpoint to prevent delayed cancer diagnosis 3
• Vaginal bleeding can contaminate urine samples and cause false-positive hematuria 2

Specific Testing to Order

Order a microscopic urinalysis with quantitative RBC/HPF reporting (not just dipstick) at 6 weeks after vaginal bleeding resolution. 1, 2 The AUA emphasizes the importance of laboratories reporting RBC/HPF quantitatively to determine whether further evaluation is warranted. 1

Do not order a urine culture unless there are signs/symptoms of infection (dysuria, urgency, fever). 2, 3 Culture is not indicated for asymptomatic hematuria evaluation. 2

What Happens Next Depends on Results

If Repeat UA Shows No Hematuria (0-2 RBCs/HPF):

• No further urologic workup needed 2
• Document as resolved and attribute to vaginal bleeding contamination 2

If Microscopic Hematuria Persists (≥3 RBCs/HPF):

You must proceed with risk-stratified urologic evaluation based on the following factors: 1, 2, 3

High-Risk Features (require cystoscopy + CT urography):

• Age ≥60 years 2, 3
• Smoking history >30 pack-years 2, 3

• 25 RBCs/HPF 2, 3

• Any history of gross hematuria 2, 3
• Occupational exposure to benzenes/aromatic amines 2, 3
• Irritative voiding symptoms without infection 2, 3

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

• Age 50-59 years (women) 2, 3
• Smoking history 10-30 pack-years 2, 3
• 11-25 RBCs/HPF 2, 3

Low-Risk Features (may repeat UA in 6 months or proceed with evaluation based on patient preference):

• Age <50 years (women) 2, 3
• Never smoker or <10 pack-years 2, 3
• 3-10 RBCs/HPF 2, 3
• No additional risk factors 2, 3

Critical Pitfalls to Avoid

Never assume the hematuria was solely from vaginal bleeding without confirming resolution. 1, 2 The AUA guidelines emphasize that clinicians must use careful judgment when non-malignant conditions are present, with attention to the patient's risk factors for urologic malignancy guiding decisions. 1

Do not defer evaluation if the patient is on anticoagulation or antiplatelet therapy. 1, 2 These medications may unmask underlying pathology but do not cause hematuria themselves—patients on anticoagulants should be assessed identically to non-anticoagulated patients. 1, 3

If glomerular disease is suspected (tea-colored urine, significant proteinuria >500 mg/24 hours, dysmorphic RBCs >80%, red cell casts, elevated creatinine), refer to nephrology in addition to completing urologic evaluation if hematuria persists. 2, 3, 4