Evaluating Microscopic Hematuria
Anthony H. Chavez, MD
Kenneth M. Belkoff, DO, FACOS
Jerry M. Greenberg, MD
Shelli Hanks, MD
William C. Kuo, MD
Michael E. Levin, MD
Jenne G. Myers, MD
Jay B. Page, MD
Kalpesh R. Patel, MD
Jennifer E. Peters, MD
Steven Steinberg, MD
Eric A. Castaneda, PA-C
Stephanie L. Keresztes, PA-C
Suzanne Sexton, PA-C
The primary concern when evaluating the patient with hematuria is finding malignancy somewhere
in the urinary tract. There will always be three elements included in the work-up for this condition,
which include upper tract imaging, cystoscopy, and urine cytology. Multiple benign etiologies exist
for hematuria, which can include, urinary tract calculi, infection, radiation cystitis, and even
bleeding from a benign, friable prostate gland. In addition, patients taking anti-coagulants
chronically and those with bleeding disorders are obviously more at risk for developing blood in
the urine. In many cases, a cause is never identified. However, the diagnosis of hematuria should
always be evaluated.
Diagnosis:
As with any other clinical finding, obtaining a thorough medical history from the patient is of utmost
importance. In particular, those being evaluated for hematuria should be questioned about his/her
smoking history, prescription and over the counter medication use, recent accidents/injuries,
family history of bladder, kidney, or prostate cancer, history of kidney stones, and history of
recurrent infections. Renal function should be checked if there is no prior history of medical renal
disease, as this can be a source of asymptomatic hematuria. A urine sample should always be
collected and sent to the lab for culture and microscopy. If there is no evidence of measurable
RBCs on microscopy (< 3 RBCs/hpf), then further hematuria work-up may not be necessary.
Urine should be checked again 3-4 weeks later to confirm that hematuria has resolved. This
should also be done following treatment of an infection. If hematuria persists (>/= 3 RBCs/hpf) in
the absence of infection, the patient should then be referred to urology for upper tract imaging
based on patient risk factors and AUA guidelines, cystoscopy, and urine cytology testing.
Long-term follow up:
Cystoscopy, urine cytology, and upper tract imaging should be repeated every 3-5 years in those
patients with chronic microscopic hematuria with negative initial work-up.
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