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Microhematuria

What's new

The American Urological Association (AUA) has updated its guidelines for the evaluation of microhematuria. Changes include modifications to age groups used in risk categorization and reclassification based on repeat urinalysis. Repeat urinalysis in 6 months is recommended for low/negligible-risk patients, while cystoscopy and renal ultrasound are recommended for intermediate-risk patients. Upper tract imaging is recommended for patients with a family history of renal cell carcinoma, a known genetic renal tumor syndrome, or a personal or family history of or suspicion for Lynch syndrome, regardless of risk category. Urine cytology is suggested in certain cases, such as high-risk patients with equivocal findings or persistent microhematuria with irritative symptoms. .

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of microhematuria are prepared by our editorial team based on guidelines from the American Urological Association (AUA/SUFU 2025), the American College of Radiology (ACR 2020), and the American College of Obstetricians and Gynecologists (ACOG/AUGS 2017).
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Classification and risk stratification

Risk stratification
As per AUA/SUFU 2025 guidelines:
Categorize patients presenting with microhematuria as low/negligible-, intermediate-, or high-risk for genitourinary malignancy following the initial evaluation:
Situation
Guidance
Low/negligible (meeting all criteria)
Age < 40 years for males, < 60 years for females
Never-smoker or < 10 pack-years
3-10 RBC/hpf on a single urinalysis
No risk factors for urothelial cancer
Intermediate (meeting one or more criteria)
Age 40-59 years for males, < 60 years for females
Smoking 10-30 pack-years
11-25 RBC/hpf on a single urinalysis
Previously low/negligible-risk patient with no prior evaluation and 3-25 RBC/hpf on repeat urinalysis
Any additional risk factor for urothelial cancer (irritative LUTS, prior pelvic radiation therapy, prior cyclophosphamide/ifosfamide chemotherapy, family history of urothelial cancer or Lynch syndrome, occupational exposures to benzene chemicals or aromatic amines, such as rubber, petrochemicals, dyes, chronic indwelling foreign body in the urinary tract)
High (meeting one or more criteria)
Age ≥ 60 years for males, females should not be categorized as high-risk solely based on age
> smoking > 30 pack-years
> 25 RBC/hpf on a single urinalysis
History of gross hematuria
One ore more risk factors for urothelial cancer plus any high-risk feature
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Re-classify low/negligible-risk patients as intermediate- or high-risk based on hematuria on repeat urinalysis, and obtain risk-based evaluation in accordance with recommendations for these respective risk strata.
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Diagnostic investigations

Initial evaluation: as per AUA/SUFU 2025 guidelines, elicit a history and perform a physical examination, including BP measurement, and obtain serum creatinine in patients with microscopic hematuria to assess risk factors for genitourinary malignancy (such as detailed smoking history), medical renal disease, gynecologic, and non-malignant genitourinary causes of microscopic hematuria.
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More topics in this section

  • Initial imaging and cystoscopy

  • Urine cytology

Follow-up and surveillance

Repeat urinalysis: as per AUA/SUFU 2025 guidelines, engage in shared decision-making regarding whether to repeat urinalysis in the future in patients with a negative risk-based hematuria evaluation.
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