Version July 2025
CT: computed tomography; hpf: high-power field; RBC: red blood cell; UA: urinalysis; UTI: urinary tract infection; WBC: white blood cell.
* Patients with a positive urine dipstick for blood who do not have microscopic hematuria confirmed by microscopic examination of the sediment may have hemoglobinuria or myoglobinuria. In addition, false positive dipstick tests can be caused by the presence of semen in the urine, an alkaline urine with a pH >9, or contamination with oxidizing agents used to clean the perineum.
¶ In menstruating females, the urinalysis should be repeated later in the cycle once menstrual bleeding has ceased. If this is not possible, a tampon can be inserted, and urinalysis can be obtained after the perineum is cleansed. In patients who had hematuria identified in the setting of vigorous exercise, the urinalysis should be repeated approximately 4 to 6 weeks later during a period of no exercise. Patients with acute trauma and microscopic hematuria should have a confirmatory urinalysis after 6 weeks.
Δ The identification of RBC casts and dysmorphic RBCs by urine microscopy requires an experienced examiner (eg, nephrologist). Many clinical laboratories employ automated urine microscopic analyzers to identify cells and particles in urine; these platforms have not been shown to be as reliable as trained clinicians to distinguish RBC morphology. Clinicians should not rely upon the results of automated urine microscopy to identify signs of glomerular bleeding. If an experienced examiner is not available, referral to a nephrologist is reasonable while urologic sources of bleeding are also considered.
◊ If proteinuria is present (ie, 1+ or greater) on urine dipstick, it should be quantified with either a spot urine protein-to-creatinine ratio (UPCR) or urine albumin-to-creatinine ratio (UACR). Refer to UpToDate content on assessment of urinary protein excretion in adults for more information.
§ The risk of urothelial cancer can be assessed using the American Urological Association risk stratification system. An exception to this risk stratification system is in patients with sickle cell trait, those with a family history of kidney cancer, those with a genetic kidney tumor syndrome, or those with a personal or family history of Lynch syndrome; such patients should have imaging of the upper urinary tract regardless of their risk category.
¥ Additional risk factors for urothelial cancer include, but are not limited to, irritative lower urinary tract symptoms, prior pelvic radiation therapy, history of cyclophosphamide or ifosfamide therapy, family history of urothelial carcinoma or Lynch syndrome, occupational exposure to benzene chemicals or aromatic amines, and chronic indwelling foreign body int he urinary tract.
The presence of ≥1 additional risk factor for urothelial cancer alone is sufficient to categorize a patient with microscopic hematuria as intermediate risk. While such risk factors may also be present in high-risk patients, their presence alone (without other high-risk criteria) is not sufficient to categorize a patient as high risk.
‡ Hematuria as a symptom of malignancy is exceedingly rare in pregnant patients. In pregnant patients with hematuria, cystoscopy should generally be deferred, if possible, until after delivery. For those at higher risk of malignancy (eg, older age, past or current smoking history), cystoscopy can be considered during pregnancy based on shared decision making.
† Some appropriately counseled intermediate-risk patients may wish to avoid cystoscopy given its potential for causing patient anxiety and discomfort. In such patients, clinicians can offer urine cytology or validated urine-based tumor markers to assist in decisions regarding the utility of cystoscopy. Patients with negative testing have a low likelihood of having bladder cancer and may choose to forego cystoscopy. If cystoscopy is not performed, a kidney and bladder ultrasound should still be performed to evaluate the upper urinary tract, and a urinalysis should be repeated within 12 months. If the repeat urinalysis shows persistent hematuria, the patient should be advised to undergo cystoscopy.
** In nonpregnant patients who cannot undergo CT urography, magnetic resonance urography (MRU) or noncontrast imaging plus retrograde pyelogram is an alternative option. In pregnant patients, kidney and bladder ultrasound is the preferred imaging modality rather than CT urography, largely to rule out ureteral obstruction or urolithiasis; further evaluation with CT urography should be deferred until after delivery.
