I have normal hemoglobin A1c (5.4%), normal calcium (9.4 mg/dL), normal thyroid‑stimulating hormone (2.9 µIU/mL), normal renal function, blood pressure 108/63 mm Hg, and I am taking losartan, pantoprazole, atorvastatin, apixaban, levothyroxine, clonazepam, and escitalopram. After a recent bereavement I have developed increased urinary frequency, but I have had persistent microscopic hematuria for years without proteinuria and a normal urologic evaluation. What is the likely cause and how should I manage these findings?

Persistent Trace Hematuria: Likely Benign but Requires Confirmation and Monitoring

Your long-standing trace microscopic hematuria with normal urologic evaluation, no proteinuria, normal kidney function, and well-controlled blood pressure most likely represents a benign condition such as thin basement membrane nephropathy or another non-progressive glomerular variant, but you must confirm this is truly "trace" (0–2 RBCs/HPF) rather than clinically significant hematuria (≥3 RBCs/HPF), because the threshold determines whether further urologic workup is needed. 1

Understanding Your Hematuria Threshold

• Microscopic hematuria requiring urologic evaluation is defined as ≥3 red blood cells per high-power field (RBC/HPF) on microscopic examination—not dipstick alone, which has only 65–99% specificity and can produce false positives from myoglobin, hemoglobin, or contaminants. 1, 2

• If your urinalysis consistently shows 0–2 RBCs/HPF, this falls within the normal range and does not warrant extensive urologic workup (no cystoscopy, no CT urography). 1

• If your results show ≥3 RBCs/HPF on at least two of three properly collected clean-catch midstream specimens, you meet the threshold for confirmed microscopic hematuria and would require risk stratification based on age, smoking history, and other factors. 1, 2

Why Your Increased Urinary Frequency Is Likely Stress-Related

• Bereavement and acute psychological stress commonly trigger urinary frequency through autonomic nervous system activation—your normal urologic evaluation (including cystoscopy and bladder assessment by your urologist) effectively rules out structural bladder pathology. 1

• Your medications (losartan, apixaban) do not cause hematuria; anticoagulants and antiplatelet agents may unmask underlying pathology but are not primary causes of bleeding. 1, 2

• Atorvastatin is generally safe, but rosuvastatin has been associated with increased risk of hematuria (HR 1.08) and proteinuria (HR 1.17) in large observational studies—your current statin choice is appropriate. 3

What You Need to Do Now

Step 1: Confirm Your Actual RBC Count

• Request a formal microscopic urinalysis (not just dipstick) on a fresh, properly collected clean-catch midstream specimen to document the exact RBC/HPF count. 1, 2

• If the result is 0–2 RBCs/HPF, document this as within normal limits—no urologic workup is indicated, and your years of "trace hematuria" likely represent borderline-normal findings or false-positive dipsticks. 1

• If the result is ≥3 RBCs/HPF, proceed to Step 2 for risk stratification. 1, 2

Step 2: Risk Stratification (Only If ≥3 RBCs/HPF Confirmed)

Your risk factors for urologic malignancy include:

• Age: Not specified in your question, but age >40 years (especially >60 years) is a high-risk feature requiring full evaluation. 1

• Smoking history: >30 pack-years is high-risk; 10–30 pack-years is intermediate-risk; <10 pack-years or never-smoker is low-risk. 1

• Occupational exposures: Benzenes, aromatic amines, or other chemicals/dyes increase risk. 1, 2

• Degree of hematuria: >25 RBCs/HPF is high-risk; 3–10 RBCs/HPF is low-risk. 1

Step 3: Assess for Glomerular Disease Indicators

• Examine urinary sediment for dysmorphic RBCs (>80% suggests glomerular origin) and red cell casts (pathognomonic for glomerular disease)—your urologist may not have performed this specialized analysis. 1, 2

• Obtain a spot urine protein-to-creatinine ratio to quantify proteinuria accurately; dipstick "negative" is insufficient, as ratios >0.2 g/g suggest renal parenchymal disease. 1, 2

• Tea-colored or cola-colored urine would suggest glomerular bleeding—your description does not mention this, which is reassuring. 1

Monitoring Plan for Persistent Low-Level Hematuria

If Your Hematuria Is Confirmed as 0–2 RBCs/HPF (Normal Range)

• No further urologic evaluation is needed—document the finding and reassure yourself that this is within normal limits. 1

• Monitor for new symptoms: Gross (visible) hematuria, significant increase in microscopic hematuria, new urologic symptoms (dysuria, flank pain), or development of hypertension or proteinuria would trigger immediate re-evaluation. 1

If Your Hematuria Is Confirmed as ≥3 RBCs/HPF but You Are Low-Risk

• Repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring at each visit—after two consecutive negative annual urinalyses, no further testing is necessary. 1

• Consider nephrology referral if hematuria persists with development of hypertension, proteinuria (protein-to-creatinine ratio >0.2 g/g), or evidence of glomerular bleeding (dysmorphic RBCs, red cell casts). 1, 2

Addressing Your Increased Urinary Frequency

• Your normal urologic evaluation (including bladder assessment) effectively excludes structural causes—urinary frequency in the context of recent bereavement is most consistent with stress-induced bladder overactivity. 1

• Behavioral interventions (timed voiding, fluid management, stress reduction techniques) are first-line management for stress-related urinary frequency. (General medical knowledge; no specific citation available.)

• If frequency persists or worsens despite stress management, consider urodynamic evaluation—but given your normal prior workup, this is unlikely to reveal new pathology. 1

Critical Pitfalls to Avoid

• Never rely on dipstick alone—microscopic confirmation of ≥3 RBCs/HPF on at least two of three specimens is required before initiating extensive workup. 1, 2

• Do not attribute hematuria to your medications (losartan, apixaban)—these may unmask underlying pathology but do not cause hematuria themselves. 1, 2

• Do not ignore gross (visible) hematuria if it develops—this carries a 30–40% malignancy risk and requires urgent urologic referral regardless of prior negative workup. 1

• Do not assume your thyroid replacement dose is adequate based solely on TSH—nephrotic syndrome (if present) can increase levothyroxine requirements through urinary loss of thyroid hormones, though your lack of proteinuria makes this unlikely. 4

Medication Considerations

• Losartan may cause a mild decrease in hemoglobin (average 0.5 g/dL), but this does not cause hematuria and the renoprotective benefits are maintained. 5

• The combination of losartan with hydrochlorothiazide (if you were to add a diuretic) reduces proteinuria more effectively than losartan alone—but you currently have no proteinuria, so this is not indicated. 6

• Continue your current medications as prescribed—none of them explain your hematuria or urinary frequency. 1, 3, 5