Guideline sources The following summarized guidelines for the evaluation and management of microscopic hematuria are prepared by our editorial team based on guidelines from the American Urological Association (AUA/SUFU 2020), the American College of Radiology (ACR 2020), the American College of Obstetricians and Gynecologists (ACOG/AUGS 2017), and the American Urological Association (AUA 2012). 1 2 3 4 Calculator Diagnostic criteria for asymptom Guidelines 1. Screening and diagnosis Definitions: https://web.pathway.md/diseases/recMSW1b1cpaqw7Wa 1/6 6/30/23, 1:02 AM Microscopic hematuria Pathway Define microhematuria as 3 RBCs/hpf on microscopic evaluation of a single, properly collected urine specimen. B Do not diagnose microhematuria by positive dipstick testing alone. Obtain formal microscopic evaluation of the urine in patients with a positive urine dipstick test (trace blood or greater). D 2. Classification and risk stratification Risk stratification: As per AUA 2020 guidelines: Categorize patients presenting with microhematuria as low-, intermediate-, or high-risk for genitourinary malignancy following the initial evaluation: Situation Guidance Females aged < 50 years, males aged < 40 years Low (meeting all criteria) Never-smoker or < 10 pack-years 10 RBC/hpf on a single urinalysis No risk factors for urothelial cancer Females aged 50-59 years, males aged 40-59 years Intermediate (meeting any of the criteria) 10-30 pack-years of smoking 11-25 RBC/hpf on a single urinalysis Low-risk patient with no prior evaluation and 3-10 RBC/hpf on repeat urinalysis Additional risk factors for urothelial cancer (irritative LUTS, prior pelvic radiation therapy, prior cyclophosphamide/ifosfamide chemotherapy, family history of urothelial cancer or Lynch syndrome, occupational exposures to benzene chemicals or aromatic amines, such as rubber, petrochemicals, dyes, chronic indwelling foreign body in the urinary tract) Age 60 years High (meeting any of the criteria) > 30 pack-years of smoking > 25 RBC/hpf on a single urinalysis History of gross hematuria. B Re-classify low-risk patients as intermediate- or high-risk if they initially elected not to undergo cystoscopy or upper tract imaging and were found to have microhematuria on repeat urine https://web.pathway.md/diseases/recMSW1b1cpaqw7Wa 2/6 6/30/23, 1:02 AM Microscopic hematuria Pathway testing. B As per ACOG 2017 guidelines: Recognize that the risk of urinary tract malignancy in low-risk, never-smoking, < 50 years old females without gross hematuria and with < 25 RBCs/hpf is 0.5%. E Obtain evaluation in asymptomatic, low-risk, never-smoking, 35-50 years old females only in the presence of > 25 RBCs/hpf. E 3. Diagnostic investigations Initial evaluation: As per SUFU 2020 guidelines: Elicit history and perform a physical examination in patients with microhematuria to assess risk factors for genitourinary malignancy, renal disease, gynecologic and non-malignant genitourinary causes of microhematuria. B Use appropriate physical examination techniques and tests in patients with findings suggestive of a gynecologic or non-malignant urologic etiology to identify such an etiology. B As per AUA 2012 guidelines: Elicit a careful history, perform a physical examination, and obtain laboratory testing to rule out benign causes of asymptomatic microhematuria, such as infection, menstruation, vigorous exercise, medical renal disease, viral illness, trauma, or recent urological procedures. B Assess renal function at the initial evaluation (including eGFR, creatinine, and BUN) because intrinsic renal disease may have implications for renal-related risk during the evaluation and management of patients with asymptomatic microscopic hematuria. B Initial imaging and cystoscopy: As per ACR 2020 guidelines: Consider obtaining CT of the abdomen and pelvis without IV contrast as initial imaging for microhematuria in patients with no risk factors or history of recent vigorous exercise, or presence of infection, viral illness, or present or recent menstruation. C Obtain an ultrasound of kidneys and bladder retroperitoneal as initial imaging for microhematuria in pregnant patients. B As per AUA 2020 guidelines, engage patients in shared decision-making to decide between repeating urinalysis within 6 months or proceeding with cystoscopy and renal ultrasound in low- risk patients with microhematuria. B Show 4 more CT/MR urography: As per ACR 2020 guidelines, obtain CT urography without and with IV contrast as initial imaging for microhematuria in patients with risk factors and without any of the following: history of recent vigorous exercise, presence of infection or viral illness, present or recent menstruation, or renal parenchymal disease. B As per AUA 2020 guidelines: https://web.pathway.md/diseases/recMSW1b1cpaqw7Wa 3/6 6/30/23, 1:02 AM Microscopic hematuria Pathway Obtain multiphasic CT urography (including imaging of the urothelium) if not contraindicated. B Consider obtaining magnetic resonance urography if multiphasic CT urography is contraindicated. C Retrograde pyelography: consider obtaining retrograde pyelography in conjunction with non- contrast axial imaging or renal ultrasound in patients with contraindications to multiphasic CT urography and magnetic resonance urography. E Urine cytology and urine markers: Do not use urine cytology or urine-based tumor markers in the initial evaluation of patients with microhematuria. D Consider obtaining urine cytology in patients with persistent microhematuria after a negative workup having irritative voiding symptoms or risk factors for carcinoma in situ. E 4. Specific circumstances Patients with family history of renal malignancy: obtain upper tract imaging in patients with microhematuria with a family history of renal cell carcinoma or a known genetic renal tumor syndrome, regardless of risk category. E Patients on antithrombotics: obtain the same evaluation of patients with microhematuria taking antiplatelet or anticoagulant agents (regardless of the type or level of therapy) as patients not taking these agents. B 5. Follow-up and surveillance Indications for specialist referral: refer patients with microhematuria for nephrologic evaluation if a renal disease is suspected, concomitantly obtain a risk-based urologic evaluation. B Serial assessment: obtain urinalysis with microscopic evaluation following treatment to ensure resolution of hematuria in patients with hematuria attributed to a UTI. B Show 5 more Evaluation of persistent or recurrent hematuria: consider obtaining additional imaging of the urinary tract in patients with persistent or recurrent microhematuria previously evaluated with renal ultrasound. C Show 3 more Clinical findings Patient demographics Past medical history Elderly age Abdominal trauma Acute bacterial prostatitis https://web.pathway.md/diseases/recMSW1b1cpaqw7Wa 4/6 6/30/23, 1:02 AM Microscopic hematuria Pathway Acute interstitial nephritis Past events Acute pyelonephritis Strenuous exercise Acute tubular necrosis Alport syndrome AntiGBM disease Benign prostatic hyperplasia Bladder cancer CKD Endometriosis Epididymitis Fabry disease Granulomatosis with polyangiitis HUS Henoch-sch nlein purpura IgA nephropathy Interstitial cystitis/painful bladder syndrome Kidney cancer Kidney stones Kidney trauma Lupus nephritis Malignant hypertension Membranoproliferative glomerulonephritis Mesangial proliferative glomerulonephritis Neurogenic bladder Nutcracker syndrome Pelvic trauma Phimosis Polycystic kidney disease Postinfectious glomerulonephritis Poststreptococcal glomerulonephritis Prostate cancer Renal artery stenosis Renal vein thrombosis Schistosomiasis Sexually transmitted diseases Sickle cell disease UTI Urethral stricture Urethritis https://web.pathway.md/diseases/recMSW1b1cpaqw7Wa 5/6 6/30/23, 1:02 AM Microscopic hematuria Pathway Lab findings References 1. Daniel A Barocas, Stephen A Boorjian, Ronald D Alvarez et al. Microhematuria: AUA/SUFU Guideline. J Urol. 2020 Oct;204 4 778 786. Open 2. Expert Panel on Urological Imaging, Darcy J Wolfman, Jamie Marko et al. ACR Appropriateness Criteria Hematuria. J Am Coll Radiol. 2020 May;17 5S S138 S147. Open 3. Davis R, Jones JS, Barocas DA et al. Diagnosis, evaluation and follow-up of asymptomatic microhematuria AMH in adults: AUA guideline. J Urol. 2012 Dec;188 6 Suppl):2473 81. Open 4. American Urogynecologic Society. Committee Opinion No.703 Asymptomatic Microscopic Hematuria in Women. Obstet Gynecol. 2017 Jun;129 6):e168-e172. Open 5. Leah M Peterson, Henry S Reed. Hematuria. Prim Care. 2019 Jun;46 2 265 273. Open 6. Christian Bolenz, Bernd Schr ppel, Andreas Eisenhardt et al. The Investigation of Hematuria. Dtsch Arztebl Int. 2018 Nov 30;115 48 801 807. Open 7. Nirmala Pillalamarri, Dara Shalom, Sharlene Sanidad et al. The prevalence of microscopic hematuria in a cohort of women with pelvic organ prolapse. Int Urogynecol J. 2015 Jan;26 1 85 90. Open 8. Hugo You-Hsien Lin, Chun-Yu Yen, Lee-Moay Lim et al. Microscopic Haematuria and Clinical Outcomes in Patients With Stage 3 5 Nondiabetic Chronic Kidney Disease. Sci Rep. 2015 Oct 16;5 15242. Open https://web.pathway.md/diseases/recMSW1b1cpaqw7Wa 6/6