Should a urinalysis be performed at every routine physical exam in asymptomatic adults, and what clinical criteria warrant ordering it?

Urinalysis at Routine Physical Exams: Not Routinely Indicated

Routine urinalysis should NOT be performed at every physical exam in asymptomatic adults. The evidence consistently shows that screening urinalysis in asymptomatic patients has poor predictive value, rarely changes management, and is not recommended by current guidelines. 1

When Urinalysis Is NOT Indicated

Asymptomatic adults undergoing routine health maintenance do not require urinalysis. 1 The consensus based on expert opinion and case series demonstrates that:

• Abnormalities are found in up to 34% of asymptomatic patients, but these results lead to management changes less than 14% of the time 1
• Of those with management changes, less than 1% develop postoperative complications 1
• Predictive values of routine urinalysis in asymptomatic patients are poor 1
• Guideline consensus explicitly states that routine urinalysis is not recommended in asymptomatic patients 1

Specific Clinical Criteria That Warrant Urinalysis

1. Symptomatic Urinary Tract Conditions

Obtain urinalysis when patients present with:

• Dysuria, frequency, urgency, or suprapubic pain (suspected UTI) 1
• Visible blood in urine (gross hematuria) 1, 2
• New or worsening urinary incontinence 1
• Flank pain or costovertebral angle tenderness 2

2. Overactive Bladder Evaluation

A urinalysis to rule out UTI and hematuria should be performed as part of the minimum requirements when evaluating bothersome bladder storage symptoms (frequency, urgency, with or without urgency incontinence). 1

3. Long-Term Care Facility Residents with Fever

In LTCF residents suspected of having infection, urinalysis should be performed only if specific UTI-associated symptoms are present (fever, dysuria, gross hematuria, new/worsening incontinence). 1

Critical caveat: Urinalysis and urine cultures should NOT be performed for asymptomatic residents, even in long-term care facilities. 1

4. Preoperative Testing

Routine preoperative urinalysis is not recommended in asymptomatic patients, even before elective surgery. 1

Exception: Consider urinalysis only in patients undergoing:

• Surgical implantation of foreign material (prosthetic joint, heart valve) 1
• Invasive urologic procedures 1

5. Hematuria Follow-Up

For patients with a history of microscopic hematuria who underwent complete evaluation:

• Perform yearly urinalysis for persistent asymptomatic microhematuria after negative initial workup 1
• After two consecutive negative annual urinalyses, no further testing is necessary 1

Common Pitfalls to Avoid

Do not order "routine" urinalysis on asymptomatic patients simply because they are having a physical exam. 1 This practice:

• Increases healthcare costs without improving outcomes 3, 4
• May lead to false-positive results requiring unnecessary follow-up 1
• Has less than 3% diagnostic yield when performed as routine screening 4

Do not screen for asymptomatic bacteriuria in most populations. 1 Asymptomatic bacteriuria should not be treated in the general adult population, as there is no benefit and high-quality evidence of harm including antibiotic resistance. 2

Do not rely on dipstick testing alone if urinalysis is clinically indicated—microscopic examination is essential for accurate interpretation. 2, 5

Age-Specific Considerations

While some older literature suggested screening adults ≥60 years for asymptomatic bacteriuria 6, current guidelines do not support routine urinalysis screening even in elderly patients unless they are symptomatic or undergoing specific procedures. 1

The key principle: Order urinalysis based on clinical symptoms or specific indications, not as part of routine health maintenance. 1