Hematuria Evaluation in the Hospitalized

Patient
Aroop Pal, MD, Erica E. Howe, MD*

KEYWORDS
 Hematuria  Gross hematuria  Microscopic hematuria  Glomerulonephritis
 Urinary tract malignancy

HOSPITAL MEDICINE CLINICS CHECKLIST

1. Microscopic hematuria is defined as 3 or more red blood cells per high-
powered field of urinary sediment from one properly collected urinalysis spec-
imen; gross hematuria is defined as visibly red to brown discoloration of urine
with 3 or more red blood cells per high-powered field of urinary sediment.
2. The amount of hematuria does not correlate with severity of disease.
3. Patients with a potentially benign cause for their hematuria (recent exercise,
sexual intercourse, prostate examination, urological trauma or instrumenta-
tion, infection) should be reevaluated after the condition has resolved.
4. Patients with hematuria and any risk factors for a urinary tract malignancy
require further evaluation.
5. Patients with hematuria and signs or symptoms of renal disease (ie, protein-
uria, renal insufficiency, edema, dysmorphic red blood cells, or red blood
cell casts on microscopy) require further evaluation to determine both
a urologic and renal cause for their hematuria.
6. Patients with hematuria in the setting of coagulopathy must be fully evaluated
before hematuria can be attributed to anticoagulation alone.
7. Essential laboratory tests to help diagnose hematuria are renal function tests
and urinalysis with microscopy and culture.
8. Urine cytology is not a part of the routine workup of hematuria.
9. Imaging plays a key role in the diagnosis of hematuria, with multidetector
computed tomography urography the preferred modality.
10. Cystoscopy should be performed on all patients with unexplained gross
hematuria or risk factors for malignancy.
11. Patients with bladder-outlet obstruction secondary to clots require admission
and urgent intervention, including irrigation and possible mechanical clot
removal with cystoscopy.

Disclosures: Dr Pal and Dr Howe have no conflicts of interest or funding sources to disclose.
Department of Internal Medicine, University of Kansas Medical Center, 3901 Rainbow
Boulevard, Kansas City, KS 66160, USA
* Corresponding author.
E-mail address: ehowe@kumc.edu

Hosp Med Clin 2 (2013) e57–e71

http://dx.doi.org/10.1016/j.ehmc.2012.07.001
2211-5943/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
e58 Pal & Howe

DEFINITIONS

1. How is hematuria defined and classified?

Hematuria is defined as blood in the urine. Once hematuria is noted, it may be classi-
fied as either gross (visible by sight) or microscopic (detectable only by urine testing).
Gross hematuria is defined as the presence of red to brown discoloration of urine
visible to the naked eye. Gross hematuria also requires that blood be noted on urinal-
ysis. When dipstick testing is positive for hematuria, the result must be confirmed with
microscopy. A dipstick that is positive for blood does not make the diagnosis of hema-
turia alone. Both myoglobin and hemoglobin can be interpreted as blood on urine
dipstick, and thus hematuria must be confirmed. Three or more red blood cells found
per high-powered field of urine sediment meet this criterion.1 It should be noted that it
takes very little blood in the urine to turn urine red or brown; discoloration can occur
with as little as 1 mL of blood for each liter of urine. Also, several conditions can cause
the appearance of urine to become red or brown without a finding of hematuria. Box 1
lists these conditions.
Microscopic hematuria is not visible by sight and is defined as 3 or more red blood
cells per high-powered field of urinary sediment from one properly collected urinalysis
specimen.1 If the dipstick method is used and not confirmed with red blood cells on
urine sediment, a false positive may result. Box 2 lists the causes of false positives.
Blood on dipstick with fewer than 3 red blood cells per high-powered field of urinary
sediment suggests myoglobin in the urine as opposed to hemoglobin. When myoglobin
is present, a differential diagnosis for rhabdomyolysis should be considered instead.
False-negative dipstick results are rarely seen but can occur with very high concen-
trations of vitamin C in the blood or a urine pH of less than 5.1.

Box 1
Conditions that turn urine red or brown without hematuria

Drugs
Phenazopyridine
Pyridium
Phenytoin
Rifampin
Nitrofurantoin
Aminosalicylic acid
Laxatives (phenophthalein, senna)
Ibuprofen
Methyldopa
Pigmenturia
Porphyria
Serratia marcescens
Urate crystalluria
Ingestion of beets, berries, food coloring (rhodamine B)

Data from Patel JV, Chambers CV, Gomella LG. Hematuria: etiology and evaluation for the
primary care physician. Can J Urol 2008;15(Suppl 1):54–62.
 Hematuria Evaluation in the Hospitalized Patient e59

Box 2
Causes of a falsely positive finding of hematuria on dipstick alone

Alkalotic urine (pH >9)

Antiseptics (povidone-iodine)
Myoglobinuria
Bacterial peroxidases
Hypochlorite

EPIDEMIOLOGY

1. What is the incidence of hematuria?

The prevalence of microscopic hematuria in the community ranges from 0.18% to

16%, depending on the population studied and the study’s definition of hematuria.2
Microscopic hematuria may be slightly more common in women, and some studies
report an increase in prevalence with age whereas others do not.3,4 Unlike gross
hematuria, microscopic hematuria is often an incidental finding that can suggest
a urologic malignancy in 1% to 25% of these patients, or another significant
disease.1,5 Equally concerning, patients with microscopic hematuria are not referred
for further evaluation 40% to 90% of the time.3 Because the hematuria of malignancy
is often intermittent and mortality increases significantly in the more advanced stages
of bladder cancer, the American Urological Association (AUA) now recommends
further evaluation after one positive finding of hematuria on urinalysis as opposed to
the previously recommended 2 of 3 urinalyses.1,6

2. What are the most common causes of hematuria?

A logical approach to the cause of a patient’s hematuria is to think of the path urine
takes from production in the kidneys through excretion from the body. Table 1 lists
the most common causes of hematuria by organ system along this pathway. In addi-
tion, the category “Other” lists the causes that can affect any part of the renal-urinary
tract system. Urinary tract infections and nephrolithiasis account for almost 50% of all
hematuria.7 Causes of nonrenal or urinary sources of hematuria are listed in Box 3.
There are also several benign causes of hematuria that do not require further workup.
These causes are listed in Box 4.

3. Can medications cause hematuria?

Yes. A multitude of medications, as listed in Box 5, can induce hematuria. In addition,
several medications can cause other disorders that in turn lead to hematuria (eg, renal
calculi, interstitial nephritis, drug-induced vasculitis, pseudohematuria).

4. If my patient is taking blood thinners or coagulopathic, can I attribute my patient’s

hematuria to this?
No. A finding of hematuria must be fully evaluated for a renal and urologic cause before
hematuria can be attributed to anticoagulation alone; this is true regardless of the type
or severity of anticoagulation.
e60 Pal & Howe

Table 1
Common causes of hematuria

Renal Glomerular causes: Nonglomerular causes:

Glomerular bleeding Polycystic kidney disease
Glomerular disease Medullary sponge kidney
Immunoglobulin A Acute tubular necrosis
nephropathy Pyelonephritis
Thin glomerular basement Hypercalciuria
disease Hyperuricosuria
hereditary nephritis Malignant hypertension
Hemolytic uremia Hydronephrosis
Glomerulonephridites Renal vein thrombosis
Renal artery embolism
Arteriovenous
malformation
Papillary necrosis (sickle
cell disease)
Renal infarct
Solitary renal cyst
Interstitial nephritis
Ureter Strictures
Polyp
Fistula (ie, ureteroiliac)
Posterior ureteral valves
Vesiculoureteral reflux
Ureteropelvic junction
obstruction
Bladder Radiation
Cystitis (ie, infection, radiation)
Polyps
Prostate/urethra Benign prostatic hypertrophy
Prostate cancer
Urethritis/prostatitis
Urethral diverticulum
Strictures
Epididymitis
Other (can affect Exercise (ie, distance runners)
any of the Blood disorder (ie, sickle cell disease)
organ systems) Coagulopathy
Trauma
Recent instrumentation,
procedure, surgery
Tuberculosis
Schistosomiasis
Syphilis
Toxoplasmosis
Cytomegalovirus
Epstein-Barr virus
Sarcoidosis
Malaria
Lymphoma
Sjögren syndrome
Calculi
Malignancy
Vasculitis
Benign masses
Endometriosis
(continued on next page)
 Hematuria Evaluation in the Hospitalized Patient e61

Table 1
(continued)

Rare Nutcracker syndrome

Pseudohematuria
Loin-pain hematuria
Nail-patella syndrome
Fabry disease
Benign familial hematuria

Abbreviation: HSP, Henoch-Schönlein purpura.

Data from McDonald MM, Swagerty D, Wetzel L. Assessment of microscopic hematuria in adults.
Am Fam Physician 2006;73(10):1748–54.

5. What are the risk factors associated with hematuria of malignancy?

The risk factors that should alert a physician to the possibility of a urinary tract cancer
as the cause of the patient’s hematuria are listed in Box 6. Of note, the amount of
hematuria does not necessarily correlate with the severity of the underlying disease.
Thus, patients with hematuria and any risk factors for a urinary tract malignancy should
be promptly referred for further evaluation.

6. Is screening for hematuria recommended?

The United States Preventative Services Task Force does not recommend screening
for individuals at risk for bladder cancer at this time.8 However, an incidental finding of
hematuria on urinalysis should be evaluated further.

HISTORY AND EXAMINATION

1. What are the clinical features in a patient with hematuria?

A thorough history and physical examination is crucial in the initial evaluation of
a patient with hematuria. Patients with a potentially benign cause for their hematuria
should be reevaluated after the condition has resolved. There are also several preex-
isting conditions that can complicate a new finding of hematuria, such as preexisting
intrinsic renal disease, renal calculi, bladder and renal cell cancers, arteriovenous mal-
formations, and vasculitides. Because each of these conditions may also explain the
patient’s hematuria, the AUA recommends periodic evaluation at the clinician’s
discretion.1
Hematuria is often asymptomatic, but can have associated symptoms depending
on the cause. Table 2 summarizes the symptoms associated with hematuria as

Box 3
Nonurinary sources of hematuria

Menstruation
Trauma
Skin ulcers
Perineal irritation
Rectal bleeding
Factitious
e62 Pal & Howe

Box 4
Benign causes of hematuria

Recent vigorous exercise

Recent sexual intercourse
Digital prostate examination
Trauma
Benign prostatic hypertrophy
Recent urological procedure or instrumentation
Presence of infection or viral illness

related to their respective common causes. In addition, any findings suggestive of

renal disease, such as proteinuria, renal insufficiency, edema, dysmorphic red blood
cells, or red blood cell casts on microscopy, should warrant further workup for
a glomerular disease as well.

DIAGNOSIS

1. What clinical findings help guide a differential diagnosis?

Several questions should be asked in initial interview with the patient to help guide the
differential diagnosis:
 Age
 Appearance of urine

Box 5
Medications that can cause hematuria

Aminoglycosides
Amitriptyline
Analgesicsa
Anticonvulsants
Busulfan
Blood thinners
Chlorpromazine
Cyclophosphamide
Diuretics
Oral contraceptives
Penicillins (extended spectrum)
Quinine
Vincristine
a
Combination analgesics now only available by prescription in Sweden, Canada, Belgium, and
Australia.
Data from McDonald MM, Swagerty D, Wetzel L. Assessment of microscopic hematuria in
adults. Am Fam Physician 2006;73(10):1748–54.
 Hematuria Evaluation in the Hospitalized Patient e63

Box 6
Risk factors for urinary tract malignancy in patients with microscopic hematuria

Male
Age older than 35 years
Past or current smoker
Exposure to benzenes or aromatic amines
Analgesic abuse
History of gross hematuria
History of urologic disease
History of irritative voiding symptoms (ie, urgency, frequency, dysuria)
History of chronic urinary tract infections
History of exposure to known carcinogens
History of exposure to chemotherapy such as alkylating agents (ie, cyclophosphamide)
History of pelvic irradiation
History of chronic indwelling foreign body

Data from Davis RJ, Jones S, Barocas DA, et al. Diagnosis, evaluation and follow-up of asymp-
tomatic microhematuria (AMH) in adults: American Urological Association Guideline. 2012.
Available at: www.auanet.org/guidelines. Accessed June 6, 2012.

 Presence of blood clots

 Timing of hematuria (initial 5 urethra, terminal/end of stream 5 prostatic,
bladder)
 Constitutional symptoms (fever, arthritis, rash)
 Location of pain (suprapubic—bladder; flank with radiation to groin—ureters,
costovertebral angle tenderness—renal)
 Symptoms of nocturia, urinary hesitancy, polyuria with incomplete voiding in men
 Association with menstruation
 Residence or travel history to countries endemic for Schistosoma haematobium

2. What laboratory tests are used to diagnose the cause of hematuria?

Once hematuria is confirmed (Fig. 1), there are several useful tests that may be
considered depending on the clinical presentation. Urinalysis with microscopy
and culture should be ordered to confirm hematuria, evaluate for infection, and
obtain any evidence of glomerulonephritis. It is also essential to obtain renal func-
tion tests, as this may provide clues to etiology and help determine appropriate
imaging.
Other laboratory tests that are useful to consider are listed in Box 7.

3. What is the role for urine cytology and urine markers?

Current recommendations are that urine cytology and urine markers (including NMP-
22, BTA-stat, and UroVysion FISH) are not a part of the routine workup of the asymp-
tomatic microhematuria patient.1 This said, in patients with persistent microhematuria
despite negative workup and/or with risk factors for carcinoma in situ, consideration is
appropriate. The sensitivity of cytology is poor, but can be increased when obtained
with cystoscopy compared with a clean catch specimen.
e64 Pal & Howe

Table 2
Causes of hematuria and their associated signs/symptoms

Symptoms Cause
Unilateral flank pain radiating to the groin Renal calculi
Pyuria, dysuria, frequency UTI/cystitis
Peripheral edema, hypertension, proteinuria Glomerular disease/upper urinary tract
or “foamy urine”; small, thin, stringy blood disease
clots
Family history of renal disease, deafness Alport syndrome
Renal failure, hemolytic anemia, Hemolytic uremic syndrome
thrombocytopenia, recent bout of
diarrhea
Recent upper respiratory infection, flank Immunoglobulin A nephropathy
pain
Recent sepsis, endocarditis, pneumonia, Postinfectious
streptococcal infection, hepatitis B
Neuropathy, rash, weight loss, nausea, Vasculitis-induced
vomiting (symptoms variable)
Joint pain and swelling, malar rash, Systemic lupus erythematosus
photosensitivity
Large, thick blood clots (may not be present) Bladder/lower urinary tract disease
Pyuria, dysuria (can mimic other diseases such Bladder cancer
as cystitis, glomerular disease, renal calculi)
Flank pain, flank mass (may not be present) Renal cell cancer
History of instrumentation, prior UTIs, Urethral stricture
obstructive symptoms (hesitancy,
intermittency, weak stream, straining)
Temporal relation to menses Endometriosis
History of bleeding, coagulopathy, or taking Bleeding diathesisa
blood thinners

Abbreviation: UTI, urinary tract infection.

a
Hematuria should not be attributed to bleeding diathesis alone until all other potential causes
of hematuria have been ruled out.
Data from Sutton JM. Evaluation of hematuria in adults. JAMA 1990;263:2475–80; and Patel JV,
Chambers CV, Gomella LG. Hematuria: etiology and evaluation for the primary care physician. Can
J Urol 2008;15(Suppl 1):54–62.

4. What radiographic imaging modalities are most useful in diagnosing the cause of
hematuria?
A complete initial evaluation of hematuria should include imaging unless it is clear that
a benign process is the cause. Imaging is recommended in all patients with unex-
plained gross hematuria and risk factors for malignancy, regardless of transient or
persistent hematuria.

Nephrolithiasis
In patients with suspicion for renal stones, a noncontrast computed tomography (CT)
scan is the preferred modality. Renal ultrasonography is an alternative for patients in
whom radiation should be avoided.
 Hematuria Evaluation in the Hospitalized Patient e65

Fig. 1. Evaluation of red-brown urine and gross hematuria.

Glomerular Disease
In patients with clear evidence of glomerular disease, ultrasonography of the kidneys,
bladder, and retroperitoneum is the appropriate study. Ultrasonography can better
assess the parenchyma and help distinguish renal masses from cysts.
Unexplained Gross Hematuria, Transient Microscopic Hematuria with Risk Factors for
Malignancy, or Unexplained Persistent Microscopic Hematuria
Multidetector CT urography, a combination of CT with and without contrast plus intra-
venous pyelography, is the clear study of choice given its high sensitivity and speci-
ficity (Table 3). If contraindications to CT are present, alternatives may include
magnetic resonance (MR) urography, MR imaging (MRI) plus retrograde pyelograms,
or ultrasonography plus retrograde pyelograms.1,9

5. When should cystoscopy indicated?

Cystoscopy is a critical piece of the workup of hematuria, and is indicated in all

patients with unexplained gross hematuria, patients with glomerular disease but risk

Box 7
Additional laboratory tests that can be useful in patients with hematuria

Antinuclear antibody
Antistreptolysin O titer
Serum complement levels
Prostate-specific antigen
Partial thromboplastin time
Prothrombin time
Protein to creatinine ratio
Albumin to creatinine ratio
24-hour urine protein, calcium, and uric acid levels
e66 Pal & Howe

Table 3
Recommended imaging studies for all patients with hematuria not attributable to renal
parenchymal disease

Rating Radiologic Procedure

Usually appropriate CT urographya
May be appropriate X-ray intravenous urography
X-ray retrograde pyelography
US kidney, bladder, retroperitoneal
MR urography
CT abdomen and pelvis, with and without contrasta
Usually not appropriate MRI abdomen and pelvis, abdomen and pelvis, with and without
contrast
Arteriography kidney
Radiography abdomen and pelvis (KUB)

Abbreviations: CT, computed tomography; KUB, kidney, ureter, bladder; MR, magnetic resonance;
MRI, magnetic resonance imaging; US, ultrasonography.
a
Relative radiation levels very high, 10 to 30 mSv.
Data from ACR Appropriateness Criteria American College of Radiology. ACR Appropriateness
CriteriaÒ: Hematuria. 2008. Available at: http://www.acr.org/Quality-Safety/Appropriateness-
Criteria; http://guidelines.gov/content.aspx?id515763. Accessed June 18, 2012.

factors for malignancy or presence of clots, and all patients age 35 years and older
with asymptomatic microhematuria.1 The contraindications for cystoscopy are acute
infection, urethral stricture, intolerance of pain by the patient, and lidocaine or latex
allergy. The benefits of cystoscopy include the ability to visualize the entire bladder,
prostate, and urethra, and the ability to intervene directly. If an upper-tract etiology
is suspected, ureteroscopy can be performed.

6. What are postcystoscopy or ureteroscopy considerations?

It is common for the postprocedure patient to have mild hematuria and dysuria. Phe-
nazopyridine (AZO Standard [OTC]; Azo-Gesic [OTC]; Baridium [OTC]; Pyridium;
ReAzo [OTC]; UTI Relief [OTC]) is commonly used for dysuria, with anticholinergics
as an alternative for detrusor contractions. Urinary retention is also common, but
usually resolves after a few hours. Because patients with underlying benign prostatic
hypertrophy are at higher risk of urinary retention, pretreatment with a-blockers may
be useful.

MANAGEMENT

1. Which patients with hematuria should be hospitalized?

Hematuria is common, and often does not require admission to hospital. The
primary indication for admission is bladder-outlet obstruction, especially in the
setting of hydronephrosis or renal failure. These patients may present with urinary
retention and flank pain. Other indications for admission are listed in Box 8. Other
considerations for hospitalization include hematuria in the setting of pregnancy
(concern for preeclampsia, severe infection, or obstructive nephrolithiasis) and
glomerulonephritis (concern for acute development of renal failure or malignant
hypertension).
 Hematuria Evaluation in the Hospitalized Patient e67

Box 8
Nonspecific indications for hospital admission

Bladder outlet obstruction

Presence or risk of:
Hydronephrosis
Renal failure
Evidence of hemodynamic instability
Uncontrolled hypertension
Orthostatic hypotension
Shock
Severe anemia or bleeding diathesis
Severe or intractable pain
Severe nausea and vomiting
Significant comorbidities

2. How should patients with acute hematuria be managed in the inpatient setting?
Standard inpatient care with attention to stabilization of pain, vital signs, and symptoms
is recommended while determining the cause of hematuria. Identification of benign and
treatable causes is the initial focus. If a benign cause is found, treatment is directed
accordingly with arrangements for follow-up urinalysis. Once benign causes have
been ruled out, the presence of hematuria may merit a urologic evaluation.1
Although hematuria tends to not be acutely life-threatening, it is essential to monitor
for the presence of clots that can lead to ureteral or bladder-outlet obstruction.
Obstruction can lead to renal failure, bladder rupture, or sepsis. The presence of clots
is an urgent issue and typically requires a urology consult.

3. What patients require a urology consult as an inpatient?

Indications for consultation would primarily be1,10,11:

 Confirmed gross hematuria without evidence of benign cause, in patients older

than 35 years
 Presence of blood clots
 Renal or ureteral stones with evidence of sepsis secondary to urinary tract infec-
tion, acute renal failure, anuria, and/or intractable pain, nausea, or vomiting
 Renal or ureteral stones that are larger than 10 mm

4. How are clots evacuated?

Initial clot evacuation can occur at the bedside by placing a large (20F–26F), wide
lumen hematuria catheter and irrigating the bladder with sterile water or saline. Manual
irrigation may be needed, but caution is required so as to not cause bladder rupture.
Antibiotic coverage is recommended in patients with clots to help prevent infection. If
clots are unable to be cleared, urinary output is decreased, or evidence of bladder
distention is found, urgent cystoscopy is required. Once clots are cleared and the
patient has good urinary flow, a 3-way urinary drainage catheter can be placed with
continuous bladder irrigation by gravity.12
e68 Pal & Howe

5. What if hematuria persists despite cystoscopy and irrigation?

Fulguration with direct heat during cystoscopy to areas of active bleeding may assist
in stopping the bleeding. If unsuccessful, several agents including carboprost, 1% to
2% alum, or silver nitrate can be instilled with irrigation. Other options include surgical
embolization, urinary diversion (percutaneous nephrostomy), and hyperbaric oxygen
therapy in refractory cases. Cystectomy is also an available but less desirable option
if bleeding persists.12

6. If the cause of hematuria is clearly glomerulonephritis, is a urological consultation

necessary?
Although there are mixed opinions, urologic consultation should still be considered in
patients who have risk factors for malignancy or who develop acute hematuria in the
setting of chronic proteinuria or previously known glomerulonephritis.

7. What patients require nephrology consultation as an inpatient?

Indications for consultation would primarily be10:
 Acute kidney injury (defined as an increase in serum creatinine 0.3 mg/dL, an
increase in serum creatinine of more than 50%, or a reduction in urine output
to less than 0.5 mL/kg/h for 6 hours)13
 Significantly diminished renal function of unknown duration (glomerular filtration
rate <60 mL/min)
 Strong suspicion for glomerulonephritis
8. When should one consider renal biopsy in the evaluation of hematuria in the hospital
and what is the management after biopsy?
The primary indication for kidney biopsy in patients with hematuria is acute glomeru-
lonephritis. Biopsy is not indicated for asymptomatic microscopic hematuria, unless
accompanied by proteinuria-progressive renal disease.14,15 There are several relative
contraindications for renal biopsy, listed in Box 9. Management recommendations
include observing the patient for 24 hours postprocedure. The main complication of
renal biopsy is bleeding.

Box 9
Relative contraindications to renal biopsy

Active renal or perirenal infection

Hydronephrosis
Multiple, bilateral cysts or a renal tumor
Skin infection over the biopsy site
Small hyperechoic kidneys (<9 cm)
Solitary native kidney
Uncorrectable bleeding diathesis
Uncontrolled severe hypertension
An uncooperative patient

Data from Whittier WL, Korbet SM. Renal biopsy: update. Curr Opin Nephrol Hypertens
2004;13(6):661–5.
 Hematuria Evaluation in the Hospitalized Patient e69

9. What is the management of anemia in acute hematuria?

Typically the amount of blood loss is not significant. Transfusion and reversal of anti-
coagulation are options to be used as needed.

10. How should patients with chronic hematuria be managed in the inpatient setting?

Patients with chronic hematuria should be monitored for evidence of gross hematuria.
If gross hematuria occurs, management should be as noted above with a focus on
hemodynamic stability and monitoring for evidence of obstruction.

11. How should patients with hematuria be managed long term?

Because the possible causes are wide ranging, guidance of long-term management
for hematuria is limited.1 For patients with persistent asymptomatic hematuria after
a complete, negative urologic workup including imaging and cystoscopy, yearly
urinalyses should be performed (Fig. 2). If there is no recurrence of the hematuria after
2 years, no further urine testing is recommended. If the patient has persistent or recur-
rent asymptomatic microhematuria after negative initial workup, repeat evaluation
should be considered.

Fig. 2. Diagnosis, evaluation, and follow-up of patients with asymptomatic hematuria. AMH,
asymptomatic microscopic hematuria; CT, computed tomography; CTU, computed tomography–
urography; HPF, high-powered field; MH, microscopic hematuria; MR, magnetic resonance; MRI,
magnetic resonance imaging; RBC, red blood cells; UA, urinalysis. (From Davis R, Jones JS, Barocas
DA, et al. Diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults:
American Urological Association Education and Research, Inc., Ó2012; with permission. Available at:
http://www.auanet.org/content/media/asymptomatic_microhematuria_algorithm.pdf. Accessed
June 6, 2012.)
e70 Pal & Howe

PROGNOSIS

1. What is the prognosis for hematuria?

The prognosis is variable with a finding of hematuria. Most screening studies of micro-
scopic hematuria revealed a urinary tract malignancy rate of greater than 2%.1 There is
also a significant decrease in mortality in bladder cancer with early detection (5-year
survival rate for stage 1 is 88% compared with 15% for stage 4).6 There is also
increasing evidence that hematuria may correlate with worse renal outcomes,
including an increased incidence of end-stage renal disease.16 Thus follow-up is rec-
ommended even if initial workup is nondiagnostic.1

PERFORMANCE IMPROVEMENT

There are no randomized controlled trials for improved outcomes associated with
screening for bladder cancer. There are also no studies to evaluate the diagnostic
accuracy of screening tests for bladder cancer in low-risk asymptomatic patients.
Therefore, more research with a focus on large, randomized controlled trials is needed
to determine best practices.

CLINICAL GUIDELINES

Davis RJ, Jones S, Barocas DA, et al. Diagnosis, evaluation and follow-up of asymp-
tomatic microhematuria (AMH) in adults: American Urological Association Guideline.
2012. Available at: www.auanet.org/guidelines.

REFERENCES

1. Davis RJ, Jones S, Barocas DA, et al. Diagnosis, evaluation and follow-up of
Asymptomatic microhematuria (AMH) in adults: American Urological Association
Guideline. 2012. Available at: www.auanet.org/guidelines. Accessed June 6, 2012.
2. Hiatt RA, Ordonez JD. Dipstick urinalysis screening, asymptomatic microhematu-
ria, and subsequent urological cancers in a population-based sample [Erratum
appears in Cancer Epidemiol Biomarkers Prev 1994;3:523.]. Cancer Epidemiol
Biomarkers Prev 1994;3:439–43.
3. Sutton JM. Evaluation of hematuria in adults. JAMA 1990;263:2475–80.
4. Mohr DN, Offord KP, Owen RA, et al. Asymptomatic microhematuria and urologic
disease: a population-based study. JAMA 1986;256:224–9.
5. Khadra MH, Pickard RS, Charlton M, et al. A prospective analysis of 1,930 patients
with hematuria to evaluate current diagnostic practice. J Urol 2000;163:524–7.
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Cancer/BladderCancer/index. Accessed June 18, 2012.
7. Fatica R, Fowler A. Hematuria. January 1, 2009. [Online]. Available at: http://www.
clevelandclinicmeded.com/medicalpubs/diseasemanagement/nephrology/
evaluation-of-hematuria/. Accessed June 18, 2012.
8. Chou R, Dana T. Screening adults for bladder cancer: update of the 2004 evidence
review for the U.S. Preventative Services Task Force. Ann Intern Med 2010;153:
461–8.
9. ACR Appropriateness Criteria American College of Radiology. ACR Appropriate-
ness CriteriaÒ: Hematuria. 2008. Available at: http://www.acr.org/Quality-Safety/
Appropriateness-Criteria; http://guidelines.gov/content.aspx?id515763. Accessed
June 18, 2012.
 Hematuria Evaluation in the Hospitalized Patient e71

10. Jimbo M. Evaluation and management of hematuria. Prim Care 2010;37(3):461–72, vii.
11. Preminger GM, Tiselius H, Assimos DG, et al. 2007 Guideline for the manage-
ment of ureteral calculi. American Urological Association Guideline. 2007. Avail-
able at: www.auanet.org/guidelines. Accessed June 18, 2012.
12. Basler J, et al. Hemorrhagic cystitis. Updated February 10, 2012. Available at: http://
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