Urologic Oncology: Seminars and Original Investigations 32 (2014) 128 134

Original article

What is evaluation of hematuria by primary care physicians? Use of

electronic medical records to assess practice patterns with intermediate
follow-up
Anna Buteau, B.S.a,1, Casey A. Seideman, M.D.a,1, Robert S. Svatek, M.D.b,
Ramy F. Youssef, M.D.a, Gaurab Chakrabarti, B.S.a, Gary Reed, M.D.c, Deepa Bhat, M.D.c,
Yair Lotan, M.D.a,*
a

Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX

Department Urology, University of Texas Health Science Center of San Antonio, San Antonio, TX
c
Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
Received 11 June 2012; received in revised form 5 July 2012; accepted 7 July 2012

Abstract
Background: To determine whether patients found to have hematuria by their primary care physicians are evaluated according to best
practice policy.
Materials and methods: The University of Texas Southwestern Medical Center maintains institutional outpatient electronic medical
records (EMR) that are used by all providers in all specialties. We conducted an Institutional Review Board approved observational study
of patients found to have more than 5 red blood cells/high power field between March 2009 and February 2010.
Results: There were 449 patients of whom the majority were female (82%), Caucasian (39%), with microscopic hematuria (MH) (85%).
Almost 58% of patients were initially symptomatic with urinary symptoms or pain. Evaluation for the source of hematuria was limited and
included imaging (35.6%), cystoscopy (9%, and cytology (7.3%). Only 36% of men and 8% of women were referred to a urologist. No
abnormality was found in 32% and 51% of patients with gross hematuria and MH, respectively (P 0.004). There were 4 bladder tumors
and 1 renal mass detected. Male gender, ethnicity and gross (vs. microscopic) hematuria were associated with higher rate of urological
referral. Advanced age, smoking, provider practice type, and the presence of urinary symptoms were not associated with an increase rate
of urological referral. No additional cancers were diagnosed with 29-month follow-up.
Conclusions: While urinalysis remains a common diagnostic tool, most cases of both microscopic and gross hematuria are not fully
evaluated according to guidelines. Use of cystoscopy, cytology, and upper tract imaging is limited. Further studies will be needed to
determine the extent of the problem and impact on morbidity and survival. 2014 Elsevier Inc. All rights reserved.
Keywords: Primary care physicians; Hematuria; Electronic medical records; Compliance; Referral

1. Introduction
Hematuria is a highly prevalent condition affecting up to
16% of the adult population [1,2]. The condition varies by
age and gender, depending on the definition of hematuria,
and whether the testing utilizes dipstick testing or mi-

The authors declare no conflict of interest.

* Corresponding author. Tel.: 1-214-648-0483; fax: 1-214-6488786.
E-mail address: yair.lotan@utsouthwestern.edu (Y. Lotan).
1
These authors contributed equally to this work.
1078-1439/$ see front matter 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.urolonc.2012.07.001

croscopy [1,2]. Gross hematuria is defined as blood in the

urine visible without microscopy. While the exact definition of microscopic hematuria is debated, most urologists consider 3 or more red blood cells (RBCs) per high
power field (HPF) as an abnormal finding [1,2]. The
finding of microscopic hematuria is associated with urological malignancy in approximately 2%5% of patients
depending on whether the study was population-based
(lower risk) or referral-based (higher risk) [1 4]. The
risk of urological malignancy is higher in patients with
gross hematuria, ranging from 10% to 20% [57]. Furthermore, there are non-life-threatening conditions, such

A. Buteau et al. / Urologic Oncology: Seminars and Original Investigations 32 (2014) 128 134

as urinary tract infection, medical renal disease, or kidney stones, which can be found in some cases.
The evaluation of patients with hematuria is not standardized among all specialties. The American Urologic Association best practice policy recommends that all patients
with nonglomerular hematuria at high-risk for bladder cancer (especially those over age 40 years or with a history of
smoking or chemica l exposure) should be considered for a
full urological evaluation after 1 positive properly performed urinalysis [8]. In patients with suspected benign
causes for microscopic hematuria or urinary tract infection
(UTI) and low risk for malignancy based on age, smoking,
and environmental risk, a repeat urinalysis is recommended
before a complete evaluation [8]. A complete urological
evaluation of microscopic hematuria includes radiological
imaging of the upper urinary tracts followed by cystoscopic
examination of the urinary bladder [8]. A clinical practice
article by Cohen and Brown recommended complete evaluation for patients with dipstick positive for microscopic
blood who have risk factors for bladder cancer [1]. By
contrast, they recommend repeating a urinalysis for patients
at low risk prior to complete evaluation. For nonglomerular
hematuria, they recommended a helical computed tomography (CT) and cytologic evaluation of the urine. Cystoscopy
is recommended for patients over the age 50 years or risk
factors for bladder cancer.
Most studies of hematuria are based on referred populations, yet urinalyses are frequently utilized in routine evaluations by primary care physicians. The actual practice
patterns of primary care physicians are unclear and can
impact outcomes of patients with hematuria. Surveys of
primary care physicians found that only 36% 48% of patients with microscopic hematuria are referred for urological
evaluation [9,10]. A review from a health plan database
found that only 27% and 47% of women and men with
hematuria were referred to urologists [11]. Another recent
study including subjects over the age of 50 years with
greater than 10 pack/year of smoking found that only 12.8%
of patients with microscopic hematuria were referred to a
urologist for cystoscopic evaluation [12].
An important question centers on what evaluation is
performed on patients with hematuria. Complete evaluation
with cystoscopy is primarily performed by urologists, yet
the primary care physician is the gatekeeper who largely
determines which patient will receive a referral. The University of Texas Southwestern Medical Center uses computerized electronic medical records (EMR) for all inpatient
and outpatient encounters. In this study, all patients with
greater than 5 RBC/HPF were identified and charts were
reviewed to determine what testing was performed on each
individual.
The advantages of this approach is that it allows a
comprehensive understanding of practice patterns compared with just evaluating referred patients which are
subject to selection bias and survey results from primary
care providers, which could vary from actual clinical

129

practice. We also were able to follow-up on patients

regardless of evaluation to determine if cancers were
diagnosed after initial evaluation.

2. Materials and methods

The EMR at the University of Texas Southwestern Medical School was queried for all patients who underwent a
urinalysis with microscopy and had greater than 5 RBCs per
HPF between March 2009 and February 2010. The study
was approved by the local institutional review board.
Review of records identified 632 patients with urinalysis
meeting the above criteria. Patients were excluded if they
were already seeing a urologist, undergoing chemotherapy,
were recently hospitalized or catheterized, or were followed
by providers outside of our institution for part of their care.
The study population narrowed to 449 and included patients
with both gross and microscopic hematuria. Microscopic
hematuria was defined as 5 or more red blood cells per high
power field without visible blood per patient or physician
report. Gross hematuria was defined as visible blood reported by either the patient or the physician. For each
patient, progress notes, medical transcripts, imaging results,
laboratory results, and referrals were reviewed. Those patients who had 2 consecutive urinalyses with greater than 5
RBCs/HPF but without signs of infection were determined
to need further workup, and of that group, those who underwent upper urinary tract imaging and cystoscopy were
considered to have been fully evaluated. The EMR was
queried again in 1/2,012 to determine if any malignancy
(renal or bladder) was diagnosed.
Statistical analysis was performed using Fishers exact
test as a 1-tailed test, and 2 analysis with significance at
0.05. All analyses were performed with SPSS ver. 19.0
(SPSS Inc, Chicago, IL).

3. Results
Patient demographics are highlighted in Tables 1 and 2.
In this cohort, most patients were female (82%), Caucasian
(38.5%), with microscopic hematuria (85%). Most of the
patients were seen by primary care physicians with nearly
50% by internal medicine physicians. Almost 57% of the
patients were initially symptomatic with urinary symptoms
or pain. There were no statistical differences in gender,
ethnicity, and age between patients with gross and microscopic hematuria.
The extent of evaluation that patients underwent is
shown in Table 3, and Fig. 1. Of the patients who were not
immediately referred to Urology, 42.5% of patients with
microscopic hematuria and 43.9% of patients with gross
hematuria did not have a repeat urinalysis. In this group,
repeat urinalysis was performed on 57.5% of patients with
microscopic hematuria, with 21.2% and 36.3% of patients

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A. Buteau et al. / Urologic Oncology: Seminars and Original Investigations 32 (2014) 128 134

Table 1
Demographics of entire cohort
All patients
Number (%)
Total cohort
Gender
Male
Female
Ethnicity
White
Black
Hispanic
Asian
Other
Unknown
Age
Mean (median)
Range
Type of provider
Internal medicine
Family practice
OB/GYN
Other
Tobacco exposure
Current smoker
Ex smoker
Nonsmoker
Symptoms
Asymptomatic
Symptomatic

Gross
Number (%)

Microscopic
Number (%)

449 (100)

69 (15.4)

380 (84.6)

82 (18.3)
367 (81.7)

20 (24.4)
49 (13.4)

62 (75.6)
318 (86.6)

0.017

173 (38.5)
62 (13.8)
20 (4.5)
5 (1.1)
25 (5.8)
164 (36.5)

33 (19.1)
10 (16.1)
2 (10)
0 (0)
2 (8)
22 (13.4)

140 (80.9)
52 (83.9)
18 (90)
5 (100)
23 (92)
142 (86.6)

0.011

55.5 (55.5)
896

56.7 (58.5)
889

55.3 (55)
1796

0.550

222 (49.4)
47 (10.5)
46 (10.2)
134 (29.8)

39 (17.6)
11 (23.6)
8 (17.4)
11 (8.2)

183 (82.4)
36 (76.6)
38 (82.6)
123 (91.8)

0.035

38 (8.5)
92 (20.5)
319 (71)

6 (15.8)
18 (19.6)
45 (14.1)

32 (84.2)
74 (80.4)
274 (85.9)

0.440

193 (43)
256 (57)

39 (20.2)
30 (11.7)

154 (79.8)
226 (88.3)

0.010

with a positive and negative repeat urinalysis, respectively.

Thirty percent of patients had a documented urinary tract
infection, including 26% and 51% of patients with microscopic and gross hematuria, respectively. Cytology was
rarely (6.2%) performed and was positive in 2 (0.7%) patients. Cystoscopy was performed in 40 patients (9%). Imaging was performed in 160 (35.6%) of the patients with
CT, and ultrasound (US) represented most tests utilized.
Based on the evaluation performed, no abnormality was
found in 32% of patients with gross hematuria and 51% of
patients with microscopic hematuria (P 0.004) [Table 4].
A UTI was found in 51% and 26% of patients with gross
and microscopic hematuria, respectively (P 0.001). There
were 4 bladder tumors found and 1 renal tumor; but only 40
patients (9%) underwent cystoscopy and 64.4% of patients
had no imaging. The likelihood of referral was impacted by
gender, with 40% and 14% of men and women referred to
see a urologist, respectively [Table 5]. Patients with gross

P value

hematuria were also more likely to be referred. However,

there was no impact of age, type of provider, and presence
of symptoms on referral rates. Interestingly, smokers were
no more likely to be referred than nonsmokers (never and
previous).
Since patients with different clinical presentations have
different risk for cancer and different rationale for evaluation, we categorized our patient population into subgroups,
including symptomatic patients with UTI, symptomatic patients without evidence of UTI, asymptomatic gross hematuria, asymptomatic microhematuria on 2 analyses, and
asymptomatic microhematuria on a single analysis. Table 6
demonstrates the breakdown of patients. Of note, not all
patients had urine culture data available and, therefore, the
total number of patients does not equal 449. Patients with
asymptomatic gross hematuria were more likely to be referred to a urologist (P 0.041) and be diagnosed with
cancer, yet only 33% were referred. Patients with asymp-

Table 2
Age and gender demographics
Age (years)

40 (n 92)
4050 (n 82)
50 (n 275)

Males (n 82)

Females (n 367)

Gross (n 20)

Microscopic (n 62)

Gross (n 49)

Microscopic (n 318)

2 (10)
3 (15)
15 (75)

8 (13)
8 (13)
46 (74)

11 (22.4)
10 (20.4)
28 (57.2)

71 (22.3)
61 (19.2)
186 (58.5)

A. Buteau et al. / Urologic Oncology: Seminars and Original Investigations 32 (2014) 128 134

131

Table 3
Type of evaluation of entire cohort (n 449)

Repeat UA*
None
Negative
Positive
Urine culture
None
Negative
Positive
Cytology
None
Negative
Positive
Cystoscopy
None
Negative
Positive
Imaging
None
Negative
Positive
Imaging modality
CT
US
MRI
KUB
IVP
Complete evaluation
Cystoscopy upper tract imaging

All patients (n 449)

Gross (n 69)

Microscopic (n 380)

156 (42.6)
135 (36.9)
75 (20.5)

18 (11.5)
17 (12.6)
6 (8)

138 (88.5)
118 (87.4)
69 (92)

167 (37.2)
150 (33.4)
132 (29.4)

11 (6.6)
23 (15.3)
35 (26.5)

156 (93.4)
127 (84.7)
97 (73.5)

416 (92.7)
31 (6.9)
2 (0.4)

55 (13.2)
12 (38.7)
2 (100)

361 (86.8)
19 (61.3)
0 (0)

409 (91)
37 (8.2)
3 (0.8)

51 (12.5)
15 (40.5)
3 (100)

358 (87.5)
22 (59.5)
0 (0)

289 (64.4)
90 (20)
70 (15.6)

40 (13.8)
12 (13.3)
17 (24.3)

249 (86.2)
78 (86.7)
53 (75.7)

94 (20.9)
57 (12.7)
4 (1)
4 (1)
1 (0.2)
37 (8.2)

26 (27.7)
2 (3.5)
0 (0)
0 (0)
0 (0)
17 (45.9)

68 (72.3)
55 (96.5)
4 (100)
4 (100)
1 (100)
20 (54.1)

P value
0.591

0.001

0.001

0.001

0.030

0.001

* Patient population only included patients who were not immediately referred to urology (n 366).

tomatic microhematuria one time were significantly less

likely to be referred (P 0.015), and 83% had no imaging
or cystoscopic evaluation.
Among patients with symptomatic UTIs, neither smoking, age, referring physician, gender, nor ethnicity were

predictive of workup or referral. Of symptomatic patients

with no evidence of UTI, male gender was predictive of
referral (43.4% of men vs. 17.5% of women, P 0.003)
and imaging (78.3% vs. 42.1%, P 0.003). Similarly
among patients with asymptomatic gross hematuria, male

Fig. 1. Testing performed on hematuria population. (Color version of figure is available online.)

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A. Buteau et al. / Urologic Oncology: Seminars and Original Investigations 32 (2014) 128 134

Table 4
Final diagnosis of entire cohort

None
UTI
Renal cyst
Stones
Hydronephrosis
Inflammatory cystitis
Bladder diverticula
Cancer (bladder n 4,
kidney n 1)

All patients (n 449)

Gross (n 69)

Microscopic (n 380)

P value

215 (47.9)
132 (29.4)
48 (10.7)
18 (4)
6 (1.3)
3 (0.7)
1 (0.2)
5 (1.1)

22 (31.9)
35 (26.5)
7 (14.6)
6 (33.3)
1 (16.7)
3 (100)
0 (0)
5 (100)

193 (50.8)
97 (73.5)
41 (85.4)
12 (66.7)
5 (83.3)
0 (0)
1 (100)
0 (0)

0.004
0.001
0.063
0.022
0.063
0.001
0.130
0.000

gender was predictive of referral (90% of men vs. 13.8% of

women, P 0.000) and imaging (80%of men vs. 20.7%
women, P 0.001). Additionally, in this subgroup, patients
referred by primary care providers (family medicine, internal medicine) were less likely to be referred to a urologist
(17.2% of patients seen by primary care were referred, vs.
80% of patients seen by another specialist or emergency
room physician, P 0.004). Smokers with asymptomatic
microhematuria two times on analysis were more likely to
be referred to a urologist (29% vs. 22% nonsmokers, P
0.046) but there was no impact of gender, age, ethnicity, or
referring physician. Over an average of 29-months followup, no additional cancers were detected in this cohort.

4. Discussion
The finding of hematuria is vexing for clinicians. Hematuria is an alarm of a potential life-threatening disease but
frequently serves as a false alarm with as many as 70%
90% of patients with microscopic hematuria and 50% of
patients with gross hematuria undergoing a nondiagnostic
evaluation [3,7,13]. There are many benign causes of hematuria, including physical activity, trauma, viral infections, menstruation, and sexual activity that resolve in a
short period (8). While hematuria in adults is highly prevalent, affecting up to 16% of the population during their
lifetime [1], each primary care physician may only see a

Table 5
Demographics of patients referred for evaluation, referred for evaluation who did not comply and those not referred number (%)

Gender
Male
Female
Ethnicity
White
Black
Hispanic
Asian
Other
Unknown
Age
40
4050
50
Type of provider
Internal medicine
Family practice
OB/GYN
Other
Tobacco exposure
Current smoker
Ex-smoker
Nonsmoker
Symptoms
Asymptomatic
Symptomatic
Type of hematuria
Gross
Microscopic

No referral (%)

Referred (%)

P value

82 (18.3)
367 (81.7)

49 (59.8)
317 (86.4)

33 (40.2)
50 (13.6)

0.000

173 (38.5)
62 (13.8)
20 (4.5)
5 (1.1)
25 (5.8)
164 (36.5)

137 (79.2)
52 (83.9)
19 (95)
5 (100)
20 (80)
133 (81)

36 (20.8)
10 (16.1)
1 (5)
0 (0)
5 (20)
27 (16.9)

0.001

92 (20.5)
82 (18.2)
275 (61.3)

80 (87.0)
68 (83.0)
219 (79.6)

12 (13)
14 (17)
56 (20.4)

0.657

222 (49.4)
47 (10.5)
46 (10.2)
134 (29.8)

184 (82.9)
40 (85.1)
34 (74)
108 (80.6)

38 (17.1)
7 (14.9)
12 (26.1)
26 (19.4)

0.472

38 (8.5)
92 (20.5)
319 (71)

29 (76.3)
72 (78.3)
265 (83.1)

9 (23.7)
20 (21.7)
54 (16.9)

0.398

193 (43)
256 (57)

152 (78.8)
214 (83.6)

41 (21.2)
42 (16.4)

0.191

69 (15.4)
380 (84.6)

41 (59.4)
325 (85.5)

28 (40.6)
55 (14.5)

0.000

A. Buteau et al. / Urologic Oncology: Seminars and Original Investigations 32 (2014) 128 134

133

Table 6
Evaluation of patients based on clinical state

Total patients
Symptomatic UTI
All others
Symptomatic No UTI
All others
Asymptomatic GH
All others
Asymptomatic MHx2
All others
Asymptomatic MHx1
All others

Referred

449
39
410
80
369
39
410
94
355
60
389

83
10 (25.7%)
73 (17.8%)
20 (25%)
63 (17.1%)
13 (33.3%)
70 (17%)
24 (25.5%)
59 (16.6%)
4 (6.7%)
79 (20.3%)

0.167
0.178
0.041
0.138
0.015

Imaging
160
17 (43.6%)
143 (34.9%)
42 (52.5%)
118 (32%)
14 (35.9%)
146 (35.6%)
46 (48.9%)
114 (32.1%)
10 (16.7%)
150 (38.6%)

0.297
0.001
0.971
0.002
0.001

handful of cases a year. One study in the UK found that the

average general practitioner with a list size of 2000 patients
will see only 1 new case of bladder cancer every 2 years and
a new case of kidney cancer every 5 years [14]. One can
understand how it would be difficult for an individual clinician to assess the impact of management of a few patients
with microscopic hematuria. Most patients with microscopic hematuria do not have malignancy and yet, as a
whole, the absolute number of cases of bladder cancer in
patients with microscopic hematuria is significant. In a
study of urine-based tumor markers in 1,331 patients with
hematuria there were 38 cases of bladder cancer among
1,005 patients with microscopic hematuria and 39 cases of
bladder cancer among 212 cases of gross hematuria [15,16].
While the likelihood of bladder cancer is much lower in
patients with microscopic hematuria compared with gross
hematuria, the prevalence of microscopic hematuria is much
greater than gross hematuria.
In this population of patients with hematuria, very few
patients (n 37, 8.2%) underwent a complete evaluation,
including cystoscopy and upper tract imaging. Of the patients who were not immediately referred to Urology, 42.5%
of patients with microscopic hematuria and 43.9% of patients with gross hematuria did not have a repeat urinalysis.
Cytology was rarely (6.2%) performed, cystoscopy was
performed in 40 patients (9%) and imaging was performed
in 160 (35.6%) of patients with CT and US representing
most tests utilized. The population was dominated by
women (85%) and 29% of the population had urinary tract
infections. Women are much less likely than men to have
bladder cancer but women with bladder cancer are more
likely to die of their disease once diagnosed [17]. Currently,
hematuria is the main symptom used to diagnose bladder
cancer and no screening is recommended. As a consequence, 25% of patients present with advanced disease and
up to 50% of these patients will die of their disease within
5 years [17]. Delays of diagnosis are one potential cause for
the high rate of invasive disease at diagnosis and can impact
cancer-related mortality [18]. This may be more significant
in women since UTIs are often blamed as the source of
hematuria.

Cystoscopy
40
8 (20.5%)
32 (7.1%)
9 (11.3%)
31 (8.4%)
6 (15.4%)
34 (8.3%)
15 (16%)
25 (7%)
0
40 (10.3%)

0.015
0.392
0.137
0.013
0.005

Cancer
5*
1 (2.6%)
3 (0.7%)
1 (1.3%)
3 (0.8%)
2 (5.1%)
2 (0.5%)
0 (0%)
4 (1.1%)
0 (0%)
4 (1%)

No evaluation

0.485
0.836
0.000
0.512
0.677

287
22 (56.4%)
265 (64.6%)
38 (47.5%)
249 (67.5%)
25 (64.1%)
262 (63.9%)
46 (48.9%)
241 (67.9%)
50 (83.3%)
237 (60.9%)

0.302
0.001
0.980
0.001
0.001

The clinical presentation of patients will usually dictate

decisions regarding evaluation. Patients with urinary tract
infections do not need further evaluation if their hematuria
resolves and there is no additional evidence of bleeding
once infection resolves. As such, it is not surprising or
inappropriate that most patients did not get a complete
evaluation but many did not get a repeat urinalysis as
recommended [8]. By contrast, patients with asymptomatic
gross hematuria are at a high (10%20%) risk of a serious
medical problem and the fact that only 40% were referred to
Urology for evaluation is concerning. Particularly dramatic
was the difference in referral and imaging based on gender
in this cohort. It is also concerning that primary care physicians were less likely to refer to urologists then emergency
room or specialists since primary care providers (PCPs) are
more likely to see patients on a routine basis or to resolve
non-urgent issues. Patients with 2 occurrences of microscopic hematuria are recommended to undergo evaluation
but this only happened 25% of the time. While smoking had
a small but significant impact on referral (29% vs. 22%
nonsmokers, P 0.046), other risk factors, such as age and
gender, did not have an effect.
The fact that previous studies have shown a higher incidence of cancer in referred populations compared to population-based studies suggests that a selection bias exists in
studies based on referrals [1 4]. The question that remains
is how and why some patients get referred while others are
simply observed? It is not clear from our population that
many patients would even meet criteria for referral. Certainly patients with gross hematuria and those who had a
repeat urinalysis that still demonstrated more than 5 RBCs/
HPF met criteria. Many of the women who had UTIs and
some of the women who never had a repeat urinalysis may
have not met criteria for further evaluation but without
repeating a urinalysis as recommended, it is not possible to
know. It is also possible that some of the patients will
develop malignancies over time. A study using the UK
general practice research database evaluated 11,138 first
occurrences of hematuria out of 762,325 patients [13]. Urinary tract malignancies occurred in 5.5% and 2.5% of
women in the first 6 months after diagnosis, respectively,

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A. Buteau et al. / Urologic Oncology: Seminars and Original Investigations 32 (2014) 128 134

but this increased to 7.4% of men and 3.4% of women by 3

years [13]. Interestingly, with an average of 29-months
follow-up, there were no additional cancers found, however,
many of the patients had no additional evaluations.
One consideration in evaluation of patients with hematuria is that the guidelines are very broad. The AUA guidelines recommend an evaluation for all patients over the age
of 40 with any risk factor, yet the incidence of bladder or
kidney cancer for a woman in her 40s who has never
smoked is incredibly low [17]. It is possible that the lack of
selectivity of the guidelines has reduced utilization even in
patients with higher risk, such as older men with a smoking
history. Our previous study in men over the age of 50 years
with 10 years smoking history found that only 12.8% of
patients with microscopic hematuria were referred to a urologist for cystoscopic evaluation [12]. Future studies to determine the adherence to guidelines and methods for improving selection of patients for evaluation are needed. It is
possible that addition of urine-based tumor markers may
improve selection of higher risk patients for evaluation [19].
Perhaps most importantly, there is a need for studies to
assess the impact of timely evaluation of hematuria on
survival from urological malignancies.
There are several limitations with this study. We arbitrarily chose 5 RBCs/HPF as a cutoff for evaluation, but
some guidelines use 23 RBCs/HPF or even dipstick positivity for blood as criteria for microhematuria. Our goal was
to be sure that the microhematuria would not be borderline but, as a consequence, we may have underestimated
the extent of the problem. Additionally, some women were
of childbearing age, and menstruation was not assessed. The
use of EMR allows a comprehensive review of all testing
performed at our institution but it is possible that some
patients were seen elsewhere and that this was not documented by their primary care physician. Upon re-examination of the EMR at a later date, there were no additional
cases of cancer diagnosed, however, this does not exclude
the possibility that patients may have transferred care, or
were lost to follow-up.

5. Conclusions
While urinalysis remains a common routine diagnostic
tool, most cases of microscopic hematuria are not fully
evaluated according to guidelines. Many patients with hematuria and either a urinary tract infection or 1 positive
urinalysis never have further evaluation. Use of cystoscopy,
cytology, and upper tract imaging is limited. Further studies
will be needed to determine the extent of the problem and
impact on morbidity and survival.

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