Evaluation of nonvisible hematuria

Diseases

Summary

Definition

Non-visible hematuria (NVH), also known as microhematuria, is the presence of three or more red blood cells (RBCs) per high-power microscope field on a midstream, clean-catch urine sample.[1]

A positive dipstick result for blood (trace blood or greater) does not confirm NVH, but should prompt further investigation with microscopy.[1]

Significance

1% to 3% of patients with NVH have urinary tract cancer.[2] [3]

Many cases of NVH are idiopathic; discrepancies between study populations may be attributable to factors including age, sex, ethnicity, occupation, and smoking status.[4] [5] [6] [7] [8] [9] [10] AUA: diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults

The prevalence of NVH in the population varies from 2.4% to 31.1%, with higher rates in men older than 60 years and men who are current or past smokers.[1] [10]

History

The most important initial diagnostic step is a detailed history, with the aim of identifying risk factors for malignancy and medical renal disease. History may also indicate less serious causes (e.g., recent exercise or sexual activity, urinary tract infection, and menstruation).

Cancer risk factors

The risk of urinary tract malignancy increases with age >40 years, male sex, degree of hematuria, persistence of hematuria, history of visible hematuria, tobacco use, previous radiation exposure, family history of urothelial cancer (previously termed transitional cell carcinoma) or Lynch syndrome, and certain occupational exposures (dyes, benzenes, aromatic amines) and medications such as cyclophosphamide or ifosfamide chemotherapy, and aristolochic acid in some herbal weight loss preparations).[8] Asymptomatic NVH is more likely to be associated with urinary tract malignancy in men.[11][3] Obesity and hypertension are risk factors for renal cell carcinoma.[12]

If malignancy is suspected, based on a high-risk or intermediate-risk profile, then evaluation of the entire urinary tract, including upper tract imaging and cystoscopy for the lower tract, is required.[1] By contrast, the workup of low-risk patients can be more focused toward the suspected cause without a complete urinary tract survey. The UK National Institute for Health and Care Excellence recommends that people ≥60 years with unexplained NVH, and either dysuria or a raised white cell count on a blood test, should be referred using a suspected cancer pathway referral for bladder cancer (for a diagnosis or ruling out of cancer within 28 days of the referral).[13]

Classification scheme

Considering the source of bleeding by anatomic site offers an organized approach. The upper urinary tract includes the kidneys (glomerular or nonglomerular) and ureters, with remaining structures in the lower urinary tract. These dividing lines are useful to apply during the history and physical exam, as well as when ordering diagnostic tests, because no single diagnostic test evaluates the urinary tract completely.

Citations

Key Articles

Barocas DA, Boorjian SA, Alvarez RD, et al. Microhematuria: AUA/SUFU Guideline. J Urol. 2020 Oct;204(4):778-86.[Abstract][Full Text]
American College of Obstetricians and Gynecologists' Committee on Gynecologic Practice, American Urogynecologic Society. Committee opinion no. 703: asymptomatic microscopic hematuria in women. Jun 2017 [Internet publication].[Full Text]
Nielsen M, Qaseem A; High Value Care Task Force of the American College of Physicians. Hematuria as a marker of occult urinary tract cancer: advice for high-value care from the American College of Physicians. Ann Intern Med. 2016;164:488-497.[Abstract][Full Text]
Linder BJ, Bass EJ, Mostafid H, et al. Guideline of guidelines: asymptomatic microscopic haematuria. BJU Int. 2018 Feb;121(2):176-83.[Abstract][Full Text]
American College of Radiology. ACR appropriateness criteria: hematuria. 2019 [internet publication].[Full Text]

Other Online Resources

AUA: diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults
American College of Physicians: hematuria as a marker of occult urinary tract cancer

Referenced Articles

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