Evaluation of nonvisible hematuria

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]

The prevalence of NVH in the population varies from 2.4% to 31.1%, depending on the study population.[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.[3] [11] Obesity and hypertension are risk factors for renal cell carcinoma.[12]

High-risk or intermediate-risk profile

If malignancy is suspected, based on a high-risk or intermediate-risk profile, then upper tract imaging and cystoscopy for the lower tract, is required.[1]

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]

Low-risk profile

Malignancy is extremely uncommon among patients with low-risk profile microhematuria.[1] These patients undergo repeat urinalysis within 6 months.

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

American Urological Association. Microhematuria: AUA/SUFU Guideline (2025). 2025 [internet publication].[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]
American College of Radiology. ACR appropriateness criteria: hematuria. 2019 [internet publication].[Full Text]

Other Online Resources

American College of Physicians: hematuria as a marker of occult urinary tract cancer

Referenced Articles

1. American Urological Association. Microhematuria: AUA/SUFU Guideline (2025). 2025 [internet publication].[Full Text]
2. Tan WS, Feber A, Sarpong R, et al. Who should be investigated for haematuria? results of a contemporary prospective observational study of 3556 patients. Eur Urol. 2018 Jul;74(1):10-4.[Abstract][Full Text]
3. Samson P, Waingankar N, Shah P, et al. Predictors of genitourinary malignancy in patients with asymptomatic microscopic hematuria. Urol Oncol. 2018 Jan;36(1):10.e1-10.e6.[Abstract][Full Text]
4. Tomson C, Porter T. Asymptomatic microscopic or dipstick haematuria in adults: which investigations for which patients? A review of the evidence. BJU Int. 2002;90:185-198.[Abstract]
5. Wollin T, Laroche B, Psooy K. Canadian guidelines for the management of asymptomatic microscopic hematuria in adults. Can Urol Assoc J. 2009:3;77-80.[Abstract][Full Text]
6. Hiatt RA, Ordonez JD. Dipstick urinalysis screening, asymptomatic microhematuria, and subsequent urological cancers in a population-based sample. Cancer Epidemiol Biomarkers Prev. 1994;3:439-443. [Published correction appears in Cancer Epidemiol Biomarkers Prev. 1994;3:523.][Abstract][Full Text]
7. Edwards TJ, Dickinson AJ, Natale S, et al. A prospective analysis of the diagnostic yield resulting from 4020 patients at a protocol-driven haematuria clinic. BJU Int. 2006;97:301-305.[Abstract]
8. Cohen RA, Brown RS. Microscopic hematuria. N Engl J Med. 2003;348:2330-2338.[Abstract]
9. Chou R, Dana T. Screening adults for bladder cancer: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;5:153:461-468.[Abstract]
10. Kang M, Lee S, Jeong SJ, et al. Characteristics and significant predictors of detecting underlying diseases in adults with asymptomatic microscopic hematuria: a large case series of a Korean population. Int J Urol. 2015 Apr;22(4):389-93.[Abstract][Full Text]
11. 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]
12. Escudier B, Porta C, Schmidinger M, et al. Renal cell carcinoma: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2019 May 1;30(5):706-20.[Abstract][Full Text]
13. National Institute for Health and Care Excellence. Suspected cancer: recognition and referral. Jan 2026 [internet publication].[Full Text]
14. Messing EM, Madeb R, Young T, et al. Long-term outcome of hematuria home screening for bladder cancer in men. Cancer. 2006;107:2173-2179.[Abstract][Full Text]
15. Friedman GD, Carroll PR, Cattolica EV, et al. Can hematuria be a predictor as well as a symptom or sign of bladder cancer? Cancer Epidemiol Biomarkers Prev. 1996;5:993-996.[Abstract][Full Text]
16. Sugimura K, Ikemoto S, Kawashima H, et al. Microscopic hematuria as a screening marker for urinary tract malignancies. Int J Urol. 2001;8:1-5.[Abstract]
17. Jones R, Latinovic R, Charlton J, et al. Alarm symptoms in early diagnosis of cancer in primary care: cohort study using general practice research database. BMJ. 2007;334:1040.[Abstract][Full Text]
18. 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]
19. Ohisa N, Kanemitsu K, Matsuki R, et al. Evaluation of hematuria using the urinary albumin-to-total-protein ratio to differentiate glomerular and nonglomerular bleeding. Clin Exp Nephrol. 2007;11:61-65.[Abstract]
20. Shen P, Ding X, Ten J, et al. Clinicopathological characteristics and outcome of adult patients with hematuria and/or proteinuria found during routine examination. Nephron Clin Pract. 2006;103:c149-56.[Abstract]
21. Cespedes RD, Peretsman SJ, Blatt SP. The significance of hematuria in patients infected with human immunodeficiency virus. J Urol. 1995;154:1455-1456.[Abstract]
22. Jones GR, Newhouse IJ, Jakobi JM, et al. The incidence of hematuria in middle distance track running. Can J Appl Physiol. 2001;26:336-349.[Abstract]
23. Worcester EM, Coe FL. Clinical practice. Calcium kidney stones. N Engl J Med. 2010 Sep 2;363(10):954-63.[Abstract][Full Text]
24. Ricketts C, Woodward ER, Killick P, et al. Germline SDHB mutations and familial renal cell carcinoma. J Natl Cancer Inst. 2008 Sep 3;100(17):1260-2.[Abstract][Full Text]
25. Steinberg GD, Carter BS, Beaty TH, et al. Family history and the risk of prostate cancer. Prostate. 1990;17(4):337-47.[Abstract]
26. Culclasure TF, Bray VJ, Hasbargen JA. The significance of hematuria in the anticoagulated patient. Arch Intern Med. 1994 Mar 28;154(6):649-52.[Abstract]
27. Tasian GE, Jemielita T, Goldfarb DS, et al. Oral antibiotic exposure and kidney stone disease. J Am Soc Nephrol. 2018 Jun;29(6):1731-40.[Abstract][Full Text]
28. Gun RT, Seymour AE, Mathew TH. A cluster of haematuria cases in a pesticide-manufacturing plant. Occup Med. 1998;48:59-62.[Full Text]
29. Alishahi S, Byrne D, Goodman CM, et al. Haematuria investigation based on a standard protocol: emphasis on the diagnosis of urological malignancy. J R Coll Surg Edinb. 2002;47:422-427.[Abstract]
30. Froom P, Ribak J, Benbassat J. Significance of microhaematuria in young adults. BMJ. 1984;288:20-22.[Abstract][Full Text]
31. Topham PS, Jethwa A, Watkins M, et al. The value of urine screening in a young adult population. Fam Pract. 2004;21:18-21.[Abstract][Full Text]
32. Paner GP, Zehnder P, Amin AM, et al. Urothelial neoplasms of the urinary bladder occurring in young adult and pediatric patients: a comprehensive review of literature with implications for patient management. Adv Anat Pathol. 2011;18:79-89.[Abstract]
33. Rodgers M, Nixon J, Hempel S, et al. Diagnostic tests and algorithms used in the investigation of haematuria: systematic reviews and economic evaluation. Health Technol Assess. 2006;10:1-259.[Abstract]
34. Yamagata K, Takahashi H, Tomida C, et al. Prognosis of asymptomatic hematuria and/or proteinuria in men. High prevalence of IgA nephropathy among proteinuria patients found in mass screening. Nephron. 2002;91:34-42.[Abstract]
35. Hall CL, Bradley R, Kerr A, et al. Clinical value of renal biopsy in patients with asymptomatic microscopic hematuria with and without low-grade proteinuria. Clin Nephrol. 2004;62:267-272.[Abstract]
36. McGregor DO, Lynn KL, Bailey RR, et al. Clinical audit of the use of renal biopsy in the management of isolated microscopic hematuria. Clin Nephrol. 1998;49:345-348.[Abstract]
37. Georgieva MV, Wheeler SB, Erim D, et al. Comparison of the harms, advantages, and costs associated with alternative guidelines for the evaluation of hematuria. JAMA Intern Med. 2019;179(10):1352-62.[Abstract]
38. Tan WS, Sarpong R, Khetrapal P, et al. Can renal and bladder ultrasound replace computerized tomography urogram in patients investigated for microscopic hematuria? J Urol. 2018 Nov;200(5):973-80.[Abstract]
39. American College of Radiology. ACR appropriateness criteria: hematuria. 2019 [internet publication].[Full Text]
40. O'Connor OJ, Maher MM. CT urography. AJR Am J Roentgenol. 2010 Nov;195(5):W320-4.[Full Text]
41. Blick CG, Nazir SA, Mallett S, et al. Evaluation of diagnostic strategies for bladder cancer using computed tomography (CT) urography, flexible cystoscopy and voided urine cytology: results for 778 patients from a hospital haematuria clinic. BJU Int. 2012 Jul;110(1):84-94.[Abstract][Full Text]
42. Abrol S, Jairath A, Ganpule S, et al. Can CT virtual cystoscopy replace conventional cystoscopy in early detection of bladder cancer? Adv Urol. 2015;2015:926590.[Abstract][Full Text]
43. Ibáñez Muñoz D, Quintana Martínez I, Fernández Militino A, et al. Virtual cystoscopy, computed tomography urography and optical cystoscopy for the detection and follow-up for bladder cancer. [in spa]. Radiologia. 2017 Sep - Oct;59(5):422-30.[Abstract][Full Text]
44. Schneider H, Ludwig M, Hossain HM, et al. The 2001 Giessen Cohort Study on patients with prostatitis syndrome--an evaluation of inflammatory status and search for microorganisms 10 years after a first analysis. Andrologia. 2003 Oct;35(5):258-62.[Abstract]
45. Grossfeld GD, Litwin MS, Wolf JS, et al. Evaluation of asymptomatic microscopic hematuria in adults: the American Urological Association best practice policy - part II: patient evaluation, cytology, voided markers, imaging, cystoscopy, nephrology evaluation, and follow-up. Urology. 2001 Apr;57(4):604-10.[Abstract]
46. Lang EK, Thomas R, Davis R, et al. Multiphasic helical computerized tomography for the assessment of microscopic hematuria: a prospective study. J Urol. 2004;171:237-243.[Abstract]
47. American College of Radiology. ACR appropriateness criteria: renal cell carcinoma staging. 2015 [internet publication].[Full Text]
48. National Institute for Health and Care Excellence. Prostate cancer: diagnosis and management. Dec 2021 [internet publication].[Full Text]
49. Drost FH, Osses DF, Nieboer D, et al. Prostate MRI, with or without MRI-targeted biopsy, and systematic biopsy for detecting prostate cancer. Cochrane Database Syst Rev. 2019 Apr 25;4:CD012663.[Abstract][Full Text]
50. Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention clinical practice guidelines: diagnosis of tuberculosis in adults and children. Clin Infect Dis. 2017 Jan 15;64(2):111-5.[Abstract][Full Text]
51. Nataraj G, Kurup S, Pandit A, et al. Correlation of fine needle aspiration cytology, smear and culture in tuberculous lymphadenitis: a prospective study. J Postgrad Med. 2002 Apr-Jun;48(2):113-6.[Abstract][Full Text]
52. Muneer A, Macrae B, Krishnamoorthy S, et al. Urogenital tuberculosis - epidemiology, pathogenesis and clinical features. Nat Rev Urol. 2019 Oct;16(10):573-98.[Abstract][Full Text]
53. Geldmacher H, Taube C, Kroeger C, et al. Assessment of lymph node tuberculosis in northern Germany: a clinical review. Chest. 2002 Apr;121(4):1177-82.[Abstract]
54. Weir MR, Thornton GF. Extrapulmonary tuberculosis. Experience of a community hospital and review of the literature. Am J Med. 1985 Oct;79(4):467-78.[Abstract]
55. Baydur A. The spectrum of extrapulmonary tuberculosis. West J Med. 1977 Apr;126(4):253-62.[Abstract][Full Text]
56. World Health Organization. WHO consolidated guidelines on tuberculosis: module 3: diagnosis: rapid diagnostics for tuberculosis detection. Mar 2024 [internet publication].[Full Text]
57. Bjerrum S, Schiller I, Dendukuri N, et al. Lateral flow urine lipoarabinomannan assay for detecting active tuberculosis in people living with HIV. Cochrane Database Syst Rev. 2019 Oct 21;10(10):CD011420.[Abstract][Full Text]

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