Microscopic hematuria

Updated June 25, 2024

Guidelines

Key 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 College of Radiology (ACR 2020), the American Urological Association (AUA/SUFU 2020), the American College of Obstetricians and Gynecologists (ACOG/AUGS 2017), and the American Urological Association (AUA 2012).

Screening and diagnosis

Definitions

As per AUA/SUFU 2020 guidelines:

Define microhematuria as ≥ 3 RBC/hpf on microscopic evaluation of a single, properly collected urine specimen.

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).

Diagnostic criteria for asymptomatic microhematuria

Presence of ≥ 3 RBC per hpf of a properly collected urinary specimen

Exclusion of an obvious benign cause

Diagnostic criteria are not met

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Classification and risk stratification

Risk stratification

As per AUA/SUFU 2020 guidelines:

Categorize patients presenting with microhematuria as low-, intermediate-, or high-risk for genitourinary malignancy following the initial evaluation:

Situation

Guidance

Low (meeting all criteria)

Females aged < 50 years, males aged < 40 years

Never-smoker or < 10 pack-years

10 RBC/hpf on a single urinalysis

No risk factors for urothelial cancer

Intermediate (meeting any of the criteria)

Females aged 50-59 years, males aged 40-59 years

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)

High (meeting any of the criteria)

Age ≥ 60 years

> 30 pack-years of smoking

> 25 RBC/hpf on a single urinalysis

History of gross hematuria

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 testing.

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Diagnostic investigations

Initial evaluation

As per AUA/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.

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.

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Specific circumstances

Patients with family history of renal malignancy: as per AUA/SUFU 2020 guidelines, 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.

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Follow-up and surveillance

Indications for specialist referral: as per AUA/SUFU 2020 guidelines, refer patients with microhematuria for nephrologic evaluation if a renal disease is suspected, concomitantly obtain a risk-based urologic evaluation.

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