urologic causes of hematuria : that is , calculi ( unenhanced phase ), renal masses ( nephrographic phase ), and upper tract urothelial tumors ( delayed phase ). However , if any other apparent GH etiology was diagnosed clinically , CTU can be obtained based on clinical suspicion . All patients with GH will require cystoscopy outpatient to rule out lower urinary tract causes of bleeding , including but not limited
Low ( patient meets all criteria )
» Women age < 50 years ; Men age < 40 years
» Never smoker or < 10 pack years
» 3-10 RBC / HPF on a single urinalysis
» No risk factors for urothelial cancer
to bladder tumors , BPH and urethral strictures .
Compared to GH , MH presents more frequently in the primary care setting and does not represent an acute event requiring urgent evaluation . Indeed , screening studies have noted a prevalence range of 2.4-31.1 % for MH . 1 The definition of MH is ≥3 red blood cells per high-power field on microscopic evaluation of a single , properly collected urine specimen . A positive dipstick cannot solely be used to diagnose MH .
PRESENTATION WITH CLOT RETENTION
• Insertion of large-bore ( ≥22 F ) 3-way Foley catheter , manual irrigation
• Identify potential risk factors , reversible causes
• Evaluate hemodynamic stability , including hemoglobin
Yes
• Conservative management with hydration
• Follow-up evaluation with cystoscopy , urine cytology , CT Urogram
• Initiation of continuous bladder irrigation with normal saline
Urine clears ?
According to the 2020 AUA Guidelines 2 , repeat UA should be performed if the patient is diagnosed with gynecologic or non-malignant genitourinary sources of microhematuria after these issues resolved . Repeat UA should be performed in the setting of MH with UTI after the UTI is resolved . Risk stratification MH workup should always be performed . The same evaluation should be performed for patients with microhematuria who are taking antiplatelet agents or
TABLE 1 : AUA MICROHEMATURIA RISK STRATIFICATION SYSTEM
• Consider clot evacuation under anesthesia +/ - fulguration of discrete bleeding vessels or tumor management
Intermediate ( patients meets any one of these criteria )
» Women age 50-59 years ; Men age 40-59 years
» 10-30 pack years » 11-25 RBC / HPF on a single urinalysis
» Low-risk patient with no prior evaluation and 3-10 RBC / HPF on repeat urinalysis
» Additional Risk factors for urothelial cancer
UROLOGY : CLINICAL UPDATES FROM THE PRACTICE
anticoagulants ( regardless of the type or level of therapy ).
So : pay attention to blood in the urine by following the guidelines , to make sure that worrisome causes of hematuria are addressed , and benign ones evaluated .
The most important message from the 2020 AUA guidelines is the risk stratification evaluation of MH . Low , intermediate and high-risk criteria are shown as table 1 .
Low risk patients can either proceed with a repeat UA in six months or complete cystoscopy and renal UA . If repeat UA is still positive , they will be either categorized as intermediate risk or high risk . Intermediate risk workup includes a cystoscopy and renal ultrasound . Cystoscopy and CTU are recommended for high-risk patients . MRI-urogram or retrograde pyelogram in addition to non-contrast CT can be performed if a CTU is contraindicated . In patients with a negative hematuria evaluation , clinicians may obtain a repeat urinalysis within 12 months . If repeat UA is negative , no further workup is warranted . If the patient has persistent MH with negative workup , cytology of urine can be obtained to rule out carcinoma in situ of urinary tract . If the patient continues to present with MH , clinicians should engage in shared decision-making regarding need for additional evaluation . Further evaluation needs to be discussed if the patient starts to present with gross hematuria or other new urologic symptoms .
References :
High ( patients meets any one of these criteria )
» Women or Men age ≥60 years
» > 30 pack years
» > 25 RBC / HPF on a single urinalysis
» History of gross hematuria
Figure 1 Management algorithm for Hematuria , Adapted from Linder , B . J , Boorgian , S . A . Management of Emergency Bleeding , Recalcitrant Clots , and Hemorrhagic Cystitis . AUA Update Series , 2015 . 34 ( 3 ): p . 17-28 .
Yes
No
• Abdominal / pelvic imaging to assess for contributing etiologies and residual clot burden
Residual clot burden ? No
1
Davis R , Jones JS , Barocas DA , Castle EP , Lang EK , Leveillee RJ , et al . Diagnosis , evaluation and follow-up of asymptomatic microhematuria ( AMH ) in adults : AUA guideline . J Urol . 2012 ; 188 ( 6 Suppl ): 2473-81 . doi : 10.1016 / j . juro . 2012.09.078 . PubMed PMID : 23098784 .
2
Barocas DA , Boorjian SA , Alvarez RD , Downs TM , Gross CP , Hamilton BD , et al . Microhematuria : AUA / SUFU Guideline . J Urol . 2020 ; 204 ( 4 ): 778-86 . doi : 10.1097 / JU . 0000000000001297 . PubMed PMID : 32698717 .
Dr . Fu is a urology resident at the University of Louisville . Dr . Talluri is a urology resident at the University of Louisville . Dr . Ankem is the Urology Department Chief at the University of Louisville .
AUGUST 2021 13