Microscopic Hematuria

Question 1

What is the definition of microhematuria?

Answer 1

Guideline 1: 3 or more RBC/HPF on a single, properly collected urine specimen (Note: This has to be RBC seen on a microscopic exam- macroscopic blood does not count- see guideline 2 below)

Guideline 2: Clinicians should not define microhematuria by positive dipstick testing alone. A positive urine dipstick of trace blood or greater should prompt formal microscopic examination of the urine.

Question 2

What should you pay particular attention to in the initial evaluation in a person with microhematuria?

Answer 2

Guideline 3: 
Perform a history and physical examination to assess risk factors for GU malignancy, medical renal disease, and non-malignant GU causes of microhemturia
-Age
-Gender
-Smoking
-LUTs
-Prior pelvic radiation
-Prior cyclophosphamide/ifosfamide chemo
-Exposure to dyes/chemicals
-Indwelling foley
-Family history of UC or lynch syndrome

Guideline 5: In persons with findings suggestive of a non-malignant or gynecology etiology, these persons should be evaluated with appropriate physical examination techniques and tests to identify the etiology. (IE: do a pelvic exam in women)

Question 3

How do you evaluate a person on anticoagulants or anti platelet drugs with microhematuria?

Answer 3

Guideline 4: They should have the same evaluation as someone not on these drugs.

Question 4

If a person is identified as having an UTI or a gynecology or non-malignant GU cause of having microhematuria, are you done with evaluation?

Answer 4

Guideline 6/7: You must obtain a urinalysis with microscopic examination to ensure resolution of the hematuria. If it persists or you can’t identify the etiology, you should perform a risk-based assessment of the microhematuria.

*** The panel acknowledges that there are some non-malignant causes such as BPH, nephrolithiasis, vaginal atrophy or prolapse, in which the MH won’t completely resolve even with appropriate management. In these cases you must use judgement and careful shared decision making to decide to pursue MH evaluation.

Question 5

If a person is thought to have microhematuria secondary to medical renal disease are you done with evaluation?

Answer 5

Guideline 8: Refer these patients to nephrology. but still do a risk based urological evaluation.

Question 6

What are the low, intermediate and high risk categories of microhematuria?

Answer 6

Low risk (must meet all criteria): women age < 50, men age < 40, never smoker or < 10 pack years, 3-10 RBC/HPF on a single UA, no risk factors for GU malignancy

Intermediate risk (meet any one criteria): women age 50-59, men age 40-59, 10-30 pack years, 11-25 RBC/HPF on a single UA, repeat UA in a low risk patient with repeat 3-10 RBC/HPF, additional risk factors for UC.

High risk (meet any one criteria): Women or men >59 years, > 30 pack years, > 25 RBC/HPF, any gross hematuria

Question 7

How should you treat a low risk person with microhematuria?

Answer 7

Guideline 10: Clinicians should engage in shared decision making to decide between repeating UA within 6 months or proceeding with cystoscopy and renal bladder ultrasound.

Question 8

How should you treat a low risk patient who has a repeat microhematuria who elected not to undergo initial evaluation?

Answer 8

Guideline 11: You should reclassify these patients as intermediate or high risk and perform cystoscopy with upper tract imaging

Question 9

How should you work up an intermediate risk patient with microhematuria?

Answer 9

Guideline 12: Clinicians should perform cystoscopy and renal ultrasound

Question 10

How should you work up a high risk hematuria patient?

Answer 10

Guideline 13: Cystoscopy and upper tract imaging:
1st preference is multiphasic CT urography (if GFR >30 and no iodine allergy)
2nd preference is MR urography
3rd preference is retrograde pyelography with non-contrast axial imaging or renal ultrasound

Special exception: pregnant women get RUS with axial imaging after delivery

Question 11

What type of cystoscopy should you perform in a person with microhematuria?

Answer 11

Guideline 14: Clinicians should perform white light cystoscopy as part of the workup (blue light costs more money, time and has not been studied in this setting and may lead to unnecessary biopsies- it is NOT currently recommended)

Question 12

What may you do in someone with persistent microhematuria previously worked up by renal ultrasound?

Answer 12

Guideline 15: Perform additional imaging of the upper urinary tract

Question 13

What should you do in a intermediate risk patient with a family history of RCC or a known genetic renal tumor syndrome?

Answer 13

Guideline 16: You should get upper tract imaging

(known genetic renal tumor syndromes are: VHL, BHD, hereditary papillary RCC, hereditary leiomyomatosis RCC, and tuberous sclerosis)

Question 14

What is the role of urinary markers in the workup of microhematuria?

Answer 14

Guidelien 17: Do not use urine cytology or makers in the initial evaluation of microhematuria

Guideline 18: You may obtain urine cytology for patients with persistent microhematuria after a negative work up who have irritative voiding symptoms or risk factors for CIS

Question 15

After a negative microhematuria workup, how often should you repeat a urinalysis?

Answer 15

Guideline 19: Within 12 months

Question 16

After a negative microhematuria evaluation and negative subsequent urinalysis, what should you do?

Answer 16

Guideline 20: the UA should be repeated in 12 months after an initial negative evaluation. However, if the subsequent UA is negative, you can stop any further workup

Question 17

For persons with a prior negative microhematuria workup and persistent microhematuria, what is recommended?

Answer 17

Guideline 21: Shared decision making regarding need for additional workup

Question 18

For persons with a prior negative microhematuria workup and worsening microhematuria or gross hematuria or new symptoms, what is recommended?

Answer 18

Guideline 22: It is recommended that you have further workup though what this workup entails is not specified and it ultimately says this should be shared decision making based on patient preferences and physician judgement…..