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Microscopic Hematuria (2020 AUA Guidelines): Difference between revisions

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'''See [https://pubmed.ncbi.nlm.nih.gov/32698717/ Original Guidelines]'''
'''See [https://pubmed.ncbi.nlm.nih.gov/32698717/ Original Guidelines]'''


'''See AUA Asymptomatic Microscopic Hematuria Guidelines 2016'''
'''See [[CUA: Asymptomatic Microscopic Hematuria (2008)|CUA Asymptomatic Microscopic Hematuria Guidelines 2008]]'''


'''See [[CUA Asymptomatic Microscopic Hematuria Guidelines 2008]]'''
See [https://www.youtube.com/watch?v=FY-MAQE68dY Video Review of 2020 AUA Guidelines on Microscopic Hematuria]


== Background ==
== Background ==
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**# '''<span style="color:#ff0000">Exercise</span>'''
**# '''<span style="color:#ff0000">Exercise</span>'''
**# '''<span style="color:#ff0000">Menstrual blood</span>'''
**# '''<span style="color:#ff0000">Menstrual blood</span>'''
**# '''<span style="color:#ff0000">Povidone-iodine (betadine)</span>'''
**# '''<span style="color:#ff0000">Povidone-iodine (betadine)[https://pubmed.ncbi.nlm.nih.gov/4032677/ §]</span>'''
* '''Urine may appear red in color from ingestion of certain foods and drugs'''
* '''Urine may appear red in color from ingestion of certain foods and drugs'''
* '''<span style="color:#ff0000">Definition of MH: ≥ 3 RBCs per high powered field on microscopic examination of a single properly collected, urinary specimen. (CUA Guidelines recommend 2 positive samples)</span>'''
* '''<span style="color:#ff0000">Definition of microscopic hematuria: ≥ 3 RBCs per high powered field on microscopic examination of a single properly collected, urinary specimen. (CUA Guidelines recommend 2 positive samples)</span>'''
** '''For most initial evaluations, a random midstream clean-catch collection is sufficient.'''
** '''For most initial evaluations, a random midstream clean-catch collection is sufficient.'''
*** Patients should discard the initial 10 mL of voided urine in order to collect the midstream void.
*** Patients should discard the initial 10 mL of voided urine in order to collect the midstream void.
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** '''<span style="color:#ff0000">A positive dipstick merits microscopic examination of the urinary sediment, but does not warrant full evaluation unless microscopic evaluation confirms ≥3 RBC/HPF.</span>'''
** '''<span style="color:#ff0000">A positive dipstick merits microscopic examination of the urinary sediment, but does not warrant full evaluation unless microscopic evaluation confirms ≥3 RBC/HPF.</span>'''
*** If <3 RBC/HPF but suspicious that the findings could reflect true MH, then repeat microscopic testing may be reasonable after assessing patient risk and preference.
*** If <3 RBC/HPF but suspicious that the findings could reflect true MH, then repeat microscopic testing may be reasonable after assessing patient risk and preference.
*'''Proper Sample Collection'''
**'''For most initial evaluations, a random midstream clean-catch collection is sufficient.'''
***Patients should be instructed to discard the initial 10 mL of voided urine into the toilet in order to collect the midstream void
**Urine specimens collected immediately after prolonged recumbency (first void in morning) or the first voiding after vigorous physical or sexual activity should not be examined to assess for microhematuria.


== Diagnosis and Evaluation ==
== Diagnosis and Evaluation ==
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{| class="wikitable"
{| class="wikitable"
|
|
|'''Low (meets all criteria)'''
|'''<span style="color:#ff0000">Low (meets all criteria)'''
|'''Intermediate (any of these criteria)'''
|'''<span style="color:#ff0000">Intermediate (any of these criteria)'''
|'''High (any of these criteria)'''
|'''<span style="color:#ff0000">High (any of these criteria)'''
|-
|-
|'''Age'''
|'''Age'''
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*# '''<span style="color:#ff0000">Imaging: upper tract imaging (intermediate, high-risk, and if family history of RCC or other genetic renal tumor syndrome)</span>'''
*# '''<span style="color:#ff0000">Imaging: upper tract imaging (intermediate, high-risk, and if family history of RCC or other genetic renal tumor syndrome)</span>'''
*#* '''<span style="color:#ff0000">US for intermediate-risk</span>'''
*#* '''<span style="color:#ff0000">US for intermediate-risk</span>'''
*#** '''<span style="color:#ff0000">Optional for low-risk</span>'''
*#* '''<span style="color:#ff0000">CT urography for high-risk</span>'''
*#* '''<span style="color:#ff0000">CT urography for high-risk</span>'''
*# '''<span style="color:#ff0000">Cystoscopy (intermediate and high-risk)</span>'''
*# '''<span style="color:#ff0000">Cystoscopy (intermediate and high-risk)</span>'''
*#* '''<span style="color:#ff0000">Optional for low-risk</span>'''
**'''<span style="color:#ff0000">Low-risk patients who initially elected not to undergo cystoscopy or upper tract imaging should undergo repeat UA within 6 months'''


=== History and Physical Exam ===
=== History and Physical Exam ===
* '''History'''
 
** '''Risk factors for malignancy (12):'''
==== History ====
**# '''Age'''
* '''<span style="color:#ff0000">Signs and Symptom'''
**# '''Male sex'''
**'''Degree of hematuria'''
**# '''Smoking'''
** '''Persistence of hematuria'''
**# '''Degree of hematuria'''
** '''History of gross hematuria'''
**# '''Persistence of hematuria'''
** '''Irritative lower urinary tract symptoms'''
**# '''History of gross hematuria'''
*'''<span style="color:#ff0000">Risk factors for malignancy (8):'''
**# '''Irritative lower urinary tract symptoms'''
*# '''<span style="color:#ff0000">Age'''
**# '''Prior pelvic radiation therapy'''
*# '''<span style="color:#ff0000">Male sex'''
**# '''Prior cyclophosphamide/ifosfamide chemotherapy'''
*# '''<span style="color:#ff0000">Smoking'''
**# '''Family history of urothelial cancer or Lynch Syndrome'''
*# '''<span style="color:#ff0000">Prior pelvic radiation therapy'''
**# '''Occupational exposures to benzene chemicals or aromatic amines (e.g., rubber, petrochemicals, dyes)'''
*# '''<span style="color:#ff0000">Prior cyclophosphamide/ifosfamide chemotherapy'''
**# '''Chronic indwelling foreign body in the urinary tract'''
*# '''<span style="color:#ff0000">Family history of urothelial cancer or Lynch Syndrome'''
** '''Medical renal disease'''
*# '''<span style="color:#ff0000">Occupational exposures to benzene chemicals or aromatic amines (e.g., rubber, petrochemicals, dyes)'''
*# '''<span style="color:#ff0000">Chronic indwelling foreign body in the urinary tract'''
* '''<span style="color:#ff0000">Other causes of microscopic hematuria'''
**'''<span style="color:#ff0000">Medical renal disease'''
*** '''Proteinuria, dysmorphic RBCs, cellular casts, or renal insufficiency on urine microscopy may be associated with medical renal disease, which can cause hematuria'''
*** '''Proteinuria, dysmorphic RBCs, cellular casts, or renal insufficiency on urine microscopy may be associated with medical renal disease, which can cause hematuria'''
**** '''If medical renal disease is suspected, refer patients for nephrologic evaluation. However, risk-based urologic evaluation should still be performed.'''
**** '''If medical renal disease is suspected, refer patients for nephrologic evaluation. However, risk-based urologic evaluation should still be performed.'''
** '''Gynecologic and non-malignant genitourinary causes of MH'''
** '''<span style="color:#ff0000">Gynecologic and non-malignant genitourinary causes of MH'''
*** '''Repeat urinalysis following resolution of the gynecologic or non-malignant genitourinary cause.'''
*** '''Repeat urinalysis following resolution of the gynecologic or non-malignant genitourinary cause.'''
**** '''MH may not resolve for several weeks to a few months following treatment of a gynecologic or non-malignant cause of MH, or treatment of a UTI; waiting ≥ 3 weeks after resolution of the non-malignant etiology and ≤ 3 months would be appropriate.'''
**** '''<span style="color:#ff0000">Microscopic hematuria may not resolve for several weeks to a few months following treatment of a gynecologic or non-malignant cause of MH, or treatment of a UTI; waiting ≥ 3 weeks after resolution of the non-malignant etiology and ≤ 3 months would be appropriate.'''
***** '''If MH persists or the etiology cannot be identified, perform risk-based urologic evaluation.'''
***** '''If MH persists or the etiology cannot be identified, perform risk-based urologic evaluation.'''
**** '''Causes of MH that persist and may not require intervention (3):'''
**** '''Causes of MH that persist and may not require intervention (3):'''
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***** In these cases, use careful judgment and shared decision-making to decide whether to pursue MH evaluation. Attention to the patient’s risk factors for urologic malignancy should inform these decisions.
***** In these cases, use careful judgment and shared decision-making to decide whether to pursue MH evaluation. Attention to the patient’s risk factors for urologic malignancy should inform these decisions.
** '''MH in patients who are taking anti-coagulants requires the same evaluation evaluation regardless of the type or level of anti-coagulation therapy'''
** '''MH in patients who are taking anti-coagulants requires the same evaluation evaluation regardless of the type or level of anti-coagulation therapy'''
* '''Physical examination'''
 
** '''Blood pressure measurement +/- genitourinary examination''', as dictated by the history.
==== Physical Examination ====
*** In females, examination of the external genitalia, introitus, and periurethral tissue may identify urethral pathology or other gynecologic pathology to explain the MH.
* '''<span style="color:#ff0000">General'''
**'''<span style="color:#ff0000">Blood pressure measurement'''
* '''<span style="color:#ff0000">Genitourinary examination'''
**In females, examination of the external genitalia, introitus, and periurethral tissue may identify urethral pathology or other gynecologic pathology to explain the MH.


=== Laboratory ===
=== Laboratory ===
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=== Low-risk ===
=== Low-risk ===
* The likelihood of upper tract malignancy is exceedingly low
* The likelihood of upper tract malignancy is exceedingly low
* Clinicians should discuss cystoscopy and imaging with renal ultrasound as options for evaluation, but should also review the option to repeat UA
* '''<span style="color:#ff0000">Options (2)'''
** Repeat UA should be performed within 6 months in order to limit the delay in diagnosis of curable malignancy should an underlying cancer be present.
** '''<span style="color:#ff0000">Cystoscopy and imaging with renal ultrasound'''
** '''Low-risk patients who initially elected not to undergo cystoscopy or upper tract imaging and who are found to have microhematuria on repeat urine testing should be reclassified as intermediate- or high-risk.'''
** '''<span style="color:#ff0000">Repeat UA (should be performed within 6 months in order to limit the delay in diagnosis of curable malignancy should an underlying cancer be present)'''
*** '''In such patients, clinicians should perform cystoscopy and upper tract imaging in accordance with recommendations for these risk strata.'''
* '''<span style="color:#ff0000">Low-risk patients who initially elected not to undergo cystoscopy or upper tract imaging and who are found to have microhematuria on repeat urine testing should be reclassified as intermediate- or high-risk.'''
*** In one large study, patients who had persistent MH on repeat urine testing had a higher rate of malignancy on subsequent evaluation as compared with those who had negative repeat urine testing
** '''In such patients, clinicians should perform cystoscopy and upper tract imaging in accordance with recommendations for these risk strata.'''
** In one large study, patients who had persistent MH on repeat urine testing had a higher rate of malignancy on subsequent evaluation as compared with those who had negative repeat urine testing


== Negative evaluation ==
== Negative evaluation ==


* '''In patients with a negative hematuria evaluation, obtain a repeat urinalysis within 12 months.'''
* '''<span style="color:#ff0000">In patients with a negative hematuria evaluation, obtain a repeat urinalysis within 12 months.</span>'''
** '''Patients with a negative follow-up UA may be discharged from further hematuria evaluation given the very low risk of malignancy'''
** '''Patients with a negative follow-up UA may be discharged from further hematuria evaluation given the very low risk of malignancy'''
** '''For patients with a prior negative hematuria evaluation who have persistent or recurrent microhematuria at the time of repeat urinalysis, engage in shared decision-making regarding need for additional evaluation.'''
** '''For patients with a prior negative hematuria evaluation who have persistent or recurrent microhematuria at the time of repeat urinalysis, engage in shared decision-making regarding need for additional evaluation.'''
* '''For patients with a prior negative hematuria evaluation who develop gross hematuria, significant increase in degree of microhematuria, or new urologic symptoms, clinicians should initiate further evaluation'''
* '''For patients with a prior negative hematuria evaluation who develop gross hematuria, significant increase in degree of microhematuria, or new urologic symptoms, clinicians should initiate further evaluation'''
== References ==
* [https://pubmed.ncbi.nlm.nih.gov/32698717/ Barocas, Daniel A., et al.] "Microhematuria: Aua/sufu guideline." ''The Journal of urology'' 204.4 (2020): 778-786.
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