The Effect of Age on the Prevalence of Asymptomatic
Microscopic Hematuria
PAUL FROOM, M.D., MOSHE GROSS, M.D., JOSEPH RIBAK, M.D.,
JOSHUA BARZILAY, M.D., AND JOCHANAN BENBASSAT, M.D.
The medical files of a sample of men who had been followed by
annual examinations from 1968 through 1978 were selected, us-
ing a random number sequence from the records of the Israel
Air Force. One group of 430 men, ages 21-23 at entry, and a
second group of 264 men, ages 2S-28 at entry, were studied.
The results of the urinalysis at entry and after ten years of follow-
up were recorded. The point prevalence of all degrees of micro-
hematuria increased significantly with age in both groups. One
to three or more red blood cells (RBCs) per high-power field
(HPF) were found in 3.5% of the subjects ages 21-23 at entry
and in 14.2% in the same subjects ten years later (P = 0.001).
Similarly, one to three or more RBCs per HPF were found in
4.9% of men ages 25-28 at entry and in 11.7% of the same
subjects ten years later (P = 0.001). The authors conclude that
age needs to be taken into consideration in drawing the line
between physiologic and pathologic microhematuria. (Key
words: Age; Microscopic hematuria) Am J Clin Pathol 1986;
86:656-657
ASYMPTOMATIC isolated microhematuria is a com-
mon diagnostic problem in clinical practice. Its prevalence
has been reported as 1.2-5.2% in young adults 8 1 3 ' 6 and
in 19.2% of 432 men age 50 or older.7 The cause of mi-
crohematuria in many if not most patients remains un-
certain, even after thorough examinations.1'3'4 The am-
biguity of the significance of an incidental finding of mi-
crohematuria is compounded by the lack of a clear
definition of pathologic hematuria. Authors employing
direct red blood cell (RBC) counts by hemocytometer have
reported that hourly excretions of RBCs in healthy people
vary from none up to 1,500,000.9'121415 Authors using
the high-power field method (HPF) in studies of unse-
lected adults have reported "normal" values (95% of the
tested specimens) of less than three RBCs per
H P p 6,8,13,15,17 others have concluded that the line between
physiologic and pathologic hematuria should be drawn,
if at all, at eight RBCs per HPF. 7
Age-related differences in RBC excretion in the urine
may explain these inconsistencies. The higher normal
values of RBC excretion in the urine were derived from
data on elderly men, 7 whereas the other studies were per-
formed on young adults. 61315 ' 17 The following longitu-
Received November 14, 1985; accepted for publication March 10,
1986.
Address reprint requests to Dr. Froom: Maagan Michael, DN Menashe
37805, Israel.
656
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Israel Air Force Aeromedical Center, Tel Hashomer, and
Department of Medicine, Hadassah University at
Mount Scopus, Jerusalem, Israel
dinal study confirms that the prevalence of microhema-
turia increases significantly with age.
Methods
The medical files of a sample of men ages 18-28 in
1968 were selected, using a random number sequence
from the records of the Israel Air Force. The files of sub-
jects who had died during the survey period and those of
42 subjects who did not have urinalysis at entry and after
ten years of follow-up were excluded. One group of 430
men ages 21-23 at entry and a second group of 264 men
ages 25-28 at entry were studied. The results of urinalysis
were recorded at entry and after ten years of follow-up.
All subjects were asymptomatic at the time of examina-
tion.
Urinalysis was performed by three experienced tech-
nicians. Within three hours after patients voided, 10 mL
from the second morning voided urine was spun in ta-
pered test tubes at 750 X g for 5 minutes. The supernatant
was poured off and the remainder (0.3 mL) mixed, placed
on a slide, covered with a standard glass slip, and examined
with a X40 plane objective and X10 wide-field binoculars.
Ten to 20 HPFs were examined and the results expressed
as a range of the most common values as follows: one to
three, two to four, three to five, five to eight, and eight or
more RBCs per HPF. The prevalence at entry was com-
pared with that at follow-up and significant difference de-
termined by the chi-square test.
Results
The point prevalence of all degrees of microhematuria
increased significantly with age in both groups of subjects
who were followed for ten years (Table 1). The age-cor-
rected normal values (95% of the population) were less
than one to three RBCs per HPF for subjects ages 21-28,
less than three to five RBCs per HPF for subjects ages 3 1 -
33, and less than five to eight RBCs per HPF in subjects
ages 35-38 years.
 Vol. 86 • No. 5 BRIEF SCIENTIFIC REPORTS 657
Table 1. The Prevalence of Hematuria in Men Followed for Ten Years
Red Blood Cells per High Power Field (equal or more)

At Risk Age 1-3 2-4 3-5 5-8 More than

(no.)- (years) no. (%) no. (%) no. (%) no. (%) no. (%)

430 21-23 15(3.5) 11 (2.6) 6(1.4) 3 (0.7) 0(0)

31-33 61 (14.2)* 44(10.2)* 20 (4.7)* 11 (2.6)* 4 (0.9)*
264 25-28 13(4.9) 8 (3.0) 6 (2.3) 2 (0.8) 1 (0.4)
35-38 31 (11.7)* 22 (8.3)* 15(5.7)* 9 (3.4)* 7 (2.7)*

• P< 0.001.

Discussion select patients for referral, leading to the high frequency

Poor correlations between the HPF method and other
methods of detection of microhematuria have been re-
peatedly reported.2,9'12 It may be argued that quantitation
of RBC urinary excretion by direct counts using a he-
mocytometer would have been more accurate than the
method used in the present survey. We feel, however, that
the wide use of the HPF method in clinical settings justifies
extrapolation from our results to office practice.
The age-related increase in prevalence of asymptomatic
microhematuria has not been noted previously but is sup-
ported by the cross-sectional data reported by Sanders.15
He found three or more RBCs per HPF in 10 (4.4%) of
225 men ages 21-30 and 32 (10% of 321 men ages 35-
50 (P = 0.02). An increase in the prevalence of micro-
hematuria with age also is consistent with the conclusion
of Freni and associates,7 that in elderly men the line be-
tween normal and pathologic microhematuria should be
drawn at 8 RBCs per HPF.
The increased prevalence of microhematuria with age
accompanies the increased prevalence of urothelial ma-
lignancies with age.5 In men ages 50-59, the annual in-
cidence of bladder carcinoma is 15 per 100,000 popula-
tion.5 If 10%15 to 20%7 of elderly men have three or more
RBCs per HPF and, assuming that the prevalence of
urothelial neoplasms among subjects with hematuria is
unrelated to its degree,4 then only 1 case of cancer of the
bladder would be expected in 400-800 subjects with mi-
crohematuria, yet bladder carcinoma has been reported
by various referral centers in 1.8%," 11%,4 6.5%,10 and
5.9%3 of patients with microhematuria. This discrepancy
indicates that patients referred for evaluation to urologic
clinics represent a selected population. Studies of referral
practices are needed to determine how primary physicians
of cancer among patients with hematuria reported by re-
ferral centers.
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