UPDATE
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
GARY D. GROSSFELD, MARK S. LITWIN, J. STUART WOLF, JR, HEDVIG HRICAK,
CATHRYN L. SHULER, DAVID C. AGERTER, AND PETER R. CARROLL
P art I of this report (preceding article) addressed
the definition, detection, prevalence, and etiol-
ogy of asymptomatic microscopic hematuria. This
section of the best practice policy (Part II) is intended
to serve as guidance to urologists and primary care
physicians with respect to the evaluation of adult pa-
tients who may have asymptomatic microscopic
hematuria. Recommendations for a nephrology
evaluation and for patient follow-up are provided.
PATIENT EVALUATION
Patients with microscopic hematuria accompa-
nied by significant proteinuria, red blood cell
(RBC) casts, dysmorphic RBCs on microscopic
analysis of the urinary sediment, or an elevated
serum creatinine level should first undergo a gen-
eral medical evaluation or evaluation for the pres-
ence of primary renal disease (see the section In-
dications for Nephrology Evaluation). Patients
without these findings and those with risk factors
for significant urologic disease (Table I) should be
promptly referred for a urologic evaluation.
From the Department of Urology, University of California School
of Medicine, San Francisco and Program in Urologic Oncology,
University of California San Francisco/Mount Zion Comprehen-
sive Care Center, San Francisco, California; Departments of Urology
and Health Services, University of California, Los Angeles,
Schools of Medicine and Public Health, Los Angeles, California;
Department of Surgery (Urology), University of Michigan School
of Medicine, Ann Arbor, Michigan; Memorial Sloan-Kettering
Cancer Center, New York, New York; Department of Medicine, Di-
vision of Nephrology, Oregon Health Sciences University, Portland,
Oregon; and Department of Family Medicine, Mayo Medical
School and Mayo Clinic Rochester, Rochester, Minnesota
Reprint requests: Gary Grossfeld, M.D., c/o Carol Schwartz,
M.P.H., R.D., Guidelines Manager, American Urological Associ-
ation, 1120 North Charles Street, Baltimore, MD 21201-5559
Submitted: October 5, 2000, accepted (with revisions): Decem-
ber 14, 2000
© 2001, ELSEVIER SCIENCE INC.
604 ALL RIGHTS RESERVED
The initial patient evaluation should include a
careful history and physical examination. Physical
examination in the woman should include a ure-
thral and vaginal examination to exclude any local
causes of microscopic hematuria. A catheterized
urinary specimen is indicated if a clean catch spec-
imen cannot be reliably obtained (ie, evidence of
vaginal contamination on microscopic examina-
tion or obese patients). In uncircumcised men, the
foreskin should be retracted to expose the glans
penis, if possible. If a phimosis is present, a cathe-
terized urinary specimen may be required.
The laboratory analysis begins with a compre-
hensive examination of the urine and urinary sed-
iment. The number of RBCs per high-powered field
should be determined. In addition, the presence of
dysmorphic RBCs (see below) or RBC casts should
be noted. The urine should also be tested for the
presence and degree of proteinuria and any evi-
dence of urinary tract infection. The serum creati-
nine level should be measured. The remaining lab-
oratory investigation should be guided by any
specific findings on the history, physical examina-
tion, and urinalysis. A complete urologic evalua-
tion of microscopic hematuria also includes radio-
logic imaging of the upper urinary tracts followed
by cystoscopic examination of the urinary bladder.
In some cases, cytologic evaluation of exfoliated
cells in the voided urine specimen may also be
performed (see the next section).
Patients in whom a carefully performed history
suggests a “benign” cause of their microscopic he-
maturia—such as menstruation, recent vigorous
exercise, sexual activity, viral illness, or trauma—
should undergo a repeated urinalysis 48 hours af-
ter cessation of these activities.1 Should the re-
peated urinalysis be negative for hematuria, no
UROLOGY 57: 604 – 610, 2001 • 0090-4295/01/$20.00
PII S0090-4295(01)00920-7

TABLE I. Risk factors for significant disease
in patients with microscopic hematuria
Smoking history
Occupational exposure to chemicals or dyes (benzenes
or aromatic amines)
History of gross hematuria
Age ⬎40 yr
Previous urologic history
History of irritative voiding symptoms
History of urinary tract infection
Analgesic abuse (eg, phenacetin)
History of pelvic irradiation
Cyclophosphamide
additional evaluation is warranted. Patients with
persistent hematuria require evaluation as de-
scribed below.
The presence of a urinary tract infection may be
identified on urinalysis. In patients with asymp-
tomatic microscopic hematuria but with leuko-
cytes on microscopic analysis of the urinary sedi-
ment, the presence of infection should be excluded
by urine culture. Patients found to have urinary
tract infection should be treated appropriately and
the urinalysis repeated 6 weeks after treatment.1 If
the hematuria resolves after treatment, no addi-
tional evaluation into the cause of the microscopic
hematuria is necessary. However, some patients
may require additional evaluation to determine the
factors predisposing to urinary tract infection.
CYTOLOGY
Urothelial cancers, the target of a cytologic ex-
amination, are the most commonly detected malig-
nancies in patients with microscopic hematuria.
The sensitivity of voided urine cytology for detect-
ing bladder cancer ranges from 40% to 76% and is
dependent on a variety of factors, including the
number of urine specimens examined, the stage
and grade of the bladder tumor, and the expertise
of the cytopathologist. The sensitivity of bladder
wash cytology is higher than that of voided cytol-
ogy, but an invasive procedure is required.2,3
Positive urinary cytologies are virtually diagnos-
tic of the presence of urothelial cancer. Negative
urinary cytologies are less helpful to the clinician
given the high incidence of false-negative results.
Thus, a negative cytology can never completely ex-
clude the presence of a bladder tumor. However,
such a finding may exclude the presence of high-
grade tumors. A recent study has suggested that
only 15% of patients with “atypical and/or suspi-
cious” cytologic findings have underlying urinary
tract malignancy.4 The presence of hematuria or
prior urothelial malignancy is a significant risk fac-
tor for malignancy in such patients and, therefore,
UROLOGY 57 (4), 2001
all patients with hematuria and atypical or suspi-
cious voided cytologic findings should undergo a
complete evaluation, including cystoscopy.
Although cystoscopy is used routinely to evalu-
ate the lower urinary tract of patients with asymp-
tomatic microscopic hematuria, it is occasionally
deferred in very low-risk populations (see below).
Voided urinary cytology should be performed in
those who do not undergo cystoscopy, as it is
readily available and may provide important infor-
mation regarding the risk of bladder cancer. In
low-risk patients who choose to undergo initial
cystoscopy and are truly asymptomatic (ie, no irri-
tative voiding symptoms), cytology is optional. Its
limited sensitivity may not warrant routine use in
low-risk patients with microscopic hematuria for
whom bladder pathologic features have been ex-
cluded by cystoscopy.
In summary, voided urinary cytology is recom-
mended for all patients with risk factors for transi-
tional cell carcinoma (Table I) or a question of
irritative voiding symptoms, as this test can be a
useful adjunct to cystoscopic evaluation of the
bladder, especially in the case of carcinoma in situ.
For patients with asymptomatic microscopic he-
maturia without risk factors for transitional cell
carcinoma, urinary cytology or cystoscopy can be
used. Cystoscopy is then required for positive or
atypical/suspicious cytologic findings.
VOIDED MARKERS
A variety of voided urinary markers have been
evaluated in the detection of bladder cancer. Pa-
tients with bladder cancer commonly present with
microscopic hematuria, and early detection could
conceivably benefit them substantially. Literature-
based estimates of the sensitivity, specificity, posi-
tive predictive value, and negative predictive value
of the most commonly studied markers are sum-
marized in Table II (see Grossfeld and Carroll5 for
the individual studies cited).
Most studies evaluating the performance of voided
markers have examined patients with known bladder
cancer, either primary or recurrent, and have com-
pared the results obtained in these patients with re-
sults obtained in a control group without bladder
cancer. Controls have included healthy volunteers
and patients with genitourinary diseases other than
bladder cancer. Some studies have included patients
with hematuria in the control group.
However, the available data are insufficient to
recommend the routine use of voided urinary
markers in the evaluation of patients with micro-
scopic hematuria. Additional studies examining
these markers for patients with asymptomatic micro-
scopic hematuria are warranted to determine their
role in the diagnostic evaluation of such patients.
605
 TABLE II. Sensitivity, specificity, positive predictive value, and negative predictive value of
various voided urine tests for the detection of bladder cancer
Studies Sensitivity Specificity PPV NPV
Marker (n) (%) (%) (%) (%)
BTA 9 28–70 73–96 33–80 52–94
NMP22 8 48–100 61–99 29–65 60–100
BTA stat 4 57–83 33–95 20–56 70–95
BTA Trak 2 62–72 73–98 62 73
Lewis X Antigen 3 80–97 73–86 72–81 83–98
Telomerase 3 62–80 80–99 84 89
FDP 2 52–81 75–91 79 78
Cytokeratin 20 1 91 85 95 76
CD44v 1 77 100 100 76
KEY: PPV ⫽ positive predictive value; NPV ⫽ negative predictive value.

IMAGING enhanced spiral CT scan is superior to either IVU7

Imaging can be used to detect renal cell carcinoma,
transitional cell carcinoma in the pelvicaliceal system
or ureter, urolithiasis, and renal infection and, there-
fore, is an important component of the initial evalu-
ation of patients with asymptomatic microscopic
hematuria (Table III).6 –12 Imaging has limited useful-
ness with respect to the detection of bladder cancer,
which is best performed by cystoscopy.
Intravenous urography (IVU) has traditionally
been the imaging modality of choice for evaluation
of the urinary tract and is still considered by many
to be the best initial study for the evaluation of
microscopic hematuria. However, IVU by itself is
of limited sensitivity in detecting small renal
masses. For masses confirmed by contrast-en-
hanced computed tomography (CT), the sensitiv-
ity of IVU is only 21%, 52%, and 85% for masses
less than 2 cm, 2 to 3 cm, and greater than 3 cm,
respectively.13 Moreover, when a mass is detected
by IVU, further lesion characterization by ultra-
sonography (US), CT, or magnetic resonance im-
aging (MRI) is necessary because IVU cannot dis-
tinguish solid masses from cystic ones.
US and CT have increasingly been used either
complementary to or instead of IVU. US is an ex-
cellent modality for the detection and characteriza-
tion of renal cysts. However, its accuracy decreases
considerably in the detection of solid renal lesions,
especially those smaller than 3 cm in diameter.6
The detection rates of renal masses with contrast-
enhanced MRI are similar to those with contrast-
enhanced CT. However, CT is less expensive and
more widely available than MRI; therefore, MRI is
considered a problem-solving approach for pa-
tients who require additional imaging after CT or
US.
CT is the single best imaging modality for evalu-
ation of urinary stones, renal and perirenal infec-
tion, and associated complications. In the evalua-
tion of suspected urinary stones, the non-contrast-
or US; the sensitivity of CT is 94% to 98% com-
pared with 52% to 59% for IVU and 19% for US.8
The morphologic factors assessed by noncontrast
CT may predict the need for urologic interven-
tion.8,9 Stones larger than 5 mm that are located in
the proximal two thirds of the ureter and seen on
two or more consecutive CT images are likely to
require intervention.
TABLE III. Advantages and disadvantages of
different imaging modalities
Modality Advantages/Disadvantages
IVU Considered by many the best initial study for
evaluation of urinary tract
Widely available and most cost-efficient in
most centers
Limited sensitivity in detecting small renal
masses
Cannot distinguish solid from cystic masses;
therefore, further lesion characterization
by US, CT, or MRI is necessary
Better than US for detection of transitional
cell carcinoma in kidney or ureter
US Excellent for detection and characterization
of renal cysts
Limitations in detection of small solid lesions
(⬍3 cm)
CT Preferred modality for detection and
characterization of solid renal masses
Detection rate for renal masses comparable
to MRI, but CT is more widely available
and less expensive than MRI
Best modality for evaluation of urinary
stones, renal and perirenal infection, and
associated complications
Sensitivity of CT for detection of renal stones
94%–98% compared with 52%–59% for
IVU and 19% for US
KEY: IVU ⫽ intravenous urography; US ⫽ ultrasonography; MRI ⫽ magnetic res-
onance imaging; CT ⫽ computed tomography.
Data from Jamis-Dow et al.,6 Sourtzis et al.,7 Fielding et al.,8 Boulay et al.,9
McNicholas et al.,10 Igarashi et al.,11 and Buckley et al.12

606 UROLOGY 57 (4), 2001

 IVU is superior to US in the detection of transi-
tional cell carcinoma in the kidney or ureter. It has
been reported that CT urography with abdominal
compression results in reliable opacification of the
collecting system comparable to that seen with
IVU.10 High detection rates of transitional cell car-
cinoma on contrast-enhanced CT images have
been reported11,12; because these studies offered no
statistical analysis, the data are considered anec-
dotal. Retrograde pyelography is considered by
many to be the best imaging approach in this set-
ting, but this opinion is not based on evidence.
No data have demonstrated the impact of IVU,
US, CT, or MRI on the treatment of patients with
asymptomatic microscopic hematuria. Therefore,
evidence-based imaging guidelines cannot be for-
mulated. Using indirect evidence regarding the de-
tection of urinary tract abnormalities by imaging,
IVU, or CT examination should be considered the
method of choice. In many centers, IVU remains
the initial evaluation for upper tract imaging in
patients with microhematuria because (a) the tech-
nology is standardized, (b) previous series exam-
ining patients with microhematuria have been
based on this modality, (c) the rate of missed diag-
noses is low when IVU is followed by appropriate
studies, and (d) IVU is less expensive than CT in
most centers. The advantages of CT over IVU are
that CT has the highest efficacy for the wide range
of possible underlying abnormalities and that the
initial use of CT shortens the duration of the diag-
nostic evaluation in many patients.
If CT is chosen as the initial upper tract study,
the imaging protocol should be adapted to the di-
agnostic goals, such as the exclusion of urolithiasis
and renal neoplasm. Neither oral nor rectal con-
trast media is required. The CT protocol should
start with a noncontrast scan. If this scan demon-
strates urolithiasis in a patient who is at low risk of
an underlying malignancy, no further scanning is
needed. Low-risk patients include those who are
younger than 40 years of age with no risk factors
for transitional cell carcinoma or renal cell carci-
noma (Table I). In all other patients, including
those in whom a urinary calculus is not detected,
intravenous contrast should be administered. De-
pending on the equipment available, CT scout (to-
pogram) or KUB (plain abdominal radiography)
can be obtained at the end of the CT examination,
allowing the assessment of the ureters and bladder
in an IVU-like fashion.
In patients with a low risk of urologic malignancy
on the basis of age and history and a contraindication
to iodine contrast media (eg, elevated creatinine
level, contrast allergy), the alternatives to IVU or CT
are KUB and US. For high-risk patients with a con-
traindication to iodine contrast media, US and retro-
grade pyelography should be performed.
UROLOGY 57 (4), 2001
CYSTOSCOPY
The role of diagnostic imaging in the detection of
bladder abnormalities is limited; thus, cystoscopic
evaluation of the bladder is necessary to exclude
such pathologic findings, especially the presence of
bladder cancer. Cystoscopy allows the complete
visualization of the bladder mucosa, which is of the
utmost importance, as bladder cancer may be a
“field defect” that involves multiple areas of the
urothelium. In addition to evaluating the bladder,
cystoscopy allows complete visualization of the
urethra and the ureteral orifices.
Initial diagnostic cystoscopy can be performed
under local anesthesia using either a rigid or flexi-
ble cystoscope. Flexible cystoscopy causes less
pain during the procedure and is associated with
fewer postprocedure symptoms compared with
rigid cystoscopy.14 –16 Moreover, positioning and
patient preparation are simplified, and the proce-
dure time is less.14
Flexible cystoscopy appears to be at least equiv-
alent in diagnostic accuracy to rigid cystoscopy;
and for some lesions, such as those at the anterior
bladder neck, it may be superior.14,17 This assumes
urologist expertise. Use of flexible cystoscopy has
been widespread in the United States only since the
early 1990s, so some urologists may not have ade-
quate experience with the technique.
Cystoscopy as a component of the initial office
evaluation of microscopic hematuria is recom-
mended for all adults older than 40 years and for
those younger than 40 years with risk factors for
the development of bladder cancer such as a
smoking history, occupational chemical expo-
sure, or a history of irritative voiding symptoms.
This includes patients in whom upper tract im-
aging reveals a potentially benign source for
bleeding.
Published reports suggest that cystoscopy has a
low yield (less than 1%) in “low-risk” patients with
microscopic hematuria.18 –22 Such patients include
women and men younger than 40 years of age
without risk factors for bladder cancer (Table I).
Therefore, it may be appropriate to defer cystos-
copy in these “low-risk” patients. In such cases,
urinary cytology should be performed as described
previously (see Cytology section). It should be em-
phasized, however, that the development of gross
hematuria and/or irritative voiding symptoms (in
the absence of urinary tract infection) should
prompt referral for cystoscopy. The decision as to
when to proceed with cystoscopy in low-risk pa-
tients with persistent microscopic hematuria must
be made on an individual basis after a careful dis-
cussion between the patient and physician.
607
 INDICATIONS FOR NEPHROLOGY
EVALUATION
The presence of significant proteinuria, RBC
casts, renal insufficiency, and/or a predominance
of dysmorphic RBCs in the urine should prompt an
evaluation for renal parenchymal disease or refer-
ral to a nephrologist. Proteinuria of 1⫹ or greater
on dipstick urinalysis should prompt a 24-hour
urine collection to quantitate the degree of protein-
uria. In the absence of massive bleeding, a total
protein excretion of greater than 1 g/24 hr would
be unlikely and should prompt a more extensive
evaluation for renal parenchymal disease or a ne-
phrology referral.23 Such an evaluation should also
be considered for lower levels of proteinuria
(greater than 500 mg/24 hr), particularly if the pro-
tein excretion is increasing and/or persistent or if
other factors suggestive of renal parenchymal dis-
ease are present.
The presence of RBC casts is virtually pathogno-
monic for glomerular bleeding. When checking
the urinary sediment for RBC casts, investigators
should look at the edges of the cover glass where
casts often occur. Unfortunately, this is a relatively
insensitive marker, even in established cases of glo-
merulonephritis. For this reason, it is useful to ex-
amine the character of the RBCs.24 Dysmorphic
urinary RBCs vary in size and shape and usually
have an irregular or distorted outline. RBCs with
these characteristics are usually glomerular in ori-
gin. In contrast, the presence of normal doughnut-
shaped RBCs in the urine is generally due to bleed-
ing from the lower urinary tract. Accurate
determination of RBC morphology may require in-
verted phase contrast microscopy, as routine light
microscopy is less accurate in this regard.
The percentage of dysmorphic RBCs required to
classify the hematuria as glomerular in origin has
not been adequately defined. In general, glomeru-
lar bleeding is associated with at least 80% dysmor-
phic RBCs, and lower urinary tract bleeding is as-
sociated with at least 80% RBCs of normal
morphology. Percentages falling between these
values are indeterminate and could represent
bleeding from either source.
Glomerular disease may be associated with a vari-
ety of systemic disorders, such as lupus, vasculitis,
malignancy, and infection (ie, hepatitis and endocar-
ditis), or it may be localized to the kidney and include
membranoproliferative glomerulonephritis, IgA ne-
phropathy, and crescentic glomerulonephritis. Inter-
stitial renal disease, such as drug-induced interstitial
disease and analgesic nephropathy, may also be asso-
ciated with hematuria. A renal biopsy is usually rec-
ommended for prognosis and guidance of therapy if
systemic causes of glomerular disease are not identi-
fied in the diagnostic evaluation.
608
“Isolated” hematuria is defined by the presence
of microscopic hematuria with a negative urologic
evaluation and the absence of systemic disease, sig-
nificant proteinuria, RBC casts, or other evidence
of glomerular bleeding on microscopic examina-
tion of the urinary sediment. Several studies have
reported a high prevalence of structural abnormal-
ities on histologic examination of the kidney in
such patients.25–28 Unfortunately, these studies are
retrospective in nature and for the most part rep-
resent patients specifically referred to a nephrolo-
gist for evaluation. The frequency of abnormal biop-
sies in this setting has ranged between 47% and 83%,
with IgA nephropathy and thin basement membrane
disease constituting most of the histologic diagnoses.
The prognosis of patients with isolated hematuria
appears to be excellent. A prospective study of the
natural history of “idiopathic” nonproteinuric hema-
turia examined the outcome of 49 adult patients dur-
ing a median follow-up of 11 years.27 Of the 49 pa-
tients, 12 patients had IgA nephropathy, 13 patients
had thin basement membrane nephropathy, 20 pa-
tients had normal renal tissue, and 4 had miscella-
neous lesions. The investigators found that nonpro-
teinuric IgA nephropathy and thin basement
membrane disease carried an excellent prognosis in
relation to the development of renal insufficiency.
However, a significant number of patients developed
hypertension on follow-up and one third of the pa-
tients developed increased proteinuria.
Although renal biopsies are often performed if
casts or proteinuria are identified, the role for renal
biopsy in the patient with isolated hematuria has
not been defined. Such patients appear to have a
low risk of progressive renal disease and biopsy
results may not affect therapy in most cases (there
is no specific treatment for thin basement mem-
brane nephropathy and the best course of treat-
ment for the nonproteinuric patient with IgA ne-
phropathy remains unclear at present). However,
it is important to monitor these patients for the
development of hypertension, renal insufficiency,
and proteinuria.
FOLLOW-UP
In at least 8% to 10% of cases, no cause for he-
maturia is revealed during the initial evaluation.29
Studies show that urologic malignancy is subse-
quently diagnosed in 1% to 3% of those with
asymptomatic microscopic hematuria,30 and that
most lesions are discovered within 3 years of the
initial negative evaluation.21,31 A variety of differ-
ent regimens have been proposed for monitoring
this group of patients. The most significant issues
regarding follow-up are as follows: (a) who should
undergo follow-up; (b) what should the follow-up
entail; (c) should the follow-up be different for
UROLOGY 57 (4), 2001
FIGURE 1. Suggested follow-up regimen for patients with asymptomatic microscopic hematuria and an initial
negative urologic evaluation. (A) Low-risk patients. (B) High-risk patients. UA ⫽ urinalysis; BP ⫽ blood pressure;
HTN ⫽ hypertension.
different individuals; and (d) how long should the
follow-up continue. Although most patients with a
negative initial evaluation for asymptomatic mi-
crohematuria do not develop significant urologic
disease, some patients do. This suggests that some
form of follow-up is indicated in this population.
Because the appearance of hematuria can precede
the diagnosis of bladder cancer by several years,32
such follow-up seems especially important for
high-risk patients, including those older than 40
years of age and patients who use tobacco or have
occupational exposures that may increase their
risk of developing a genitourinary malignancy.31
Although some investigators have made firm rec-
ommendations as to how these patients should be
followed up, such recommendations have been
based on retrospective reviews of patients who
were followed up for variable periods. Conse-
UROLOGY 57 (4), 2001
quently, these recommendations have not been
rigidly tested to determine which follow-up strat-
egy (if any) is most efficient and cost-effective for
detecting significant urologic disease. Because the
risk of life-threatening lesions in this population is
low (less than 3%) and the data regarding fol-
low-up are sparse, recommendations regarding the
appropriate standard for follow-up must be based
on consensus opinion, in addition to a review of
the literature-based evidence (Fig. 1).
In patients with asymptomatic microscopic he-
maturia who have a negative initial evaluation,
consideration should be given to repeating the uri-
nalysis, voided urine cytology, and blood pressure
determination at 6, 12, 24, and 36 months. Al-
though cytology may not be a sensitive marker for
detecting low-grade transitional cell carcinoma, it
will detect most high-grade tumors and carcinoma
609
in situ, particularly if the test is repeated. Such
high-grade lesions are the most likely to benefit
from early detection. It should be emphasized,
however, that additional evaluation may be war-
ranted in patients with persistent hematuria in
whom the index of suspicion for significant under-
lying disease is high. In this setting, the clinical
judgment of the treating physician should guide
any additional evaluation. Immediate urologic re-
evaluation, with consideration of cystoscopy, cytol-
ogy, and/or repeated imaging studies, should be per-
formed if any of the following occur: development of
gross hematuria, abnormal urinary cytologic find-
ings, or irritative voiding symptoms in the absence of
infection. If none of these occur within 3 years, the
patient does not require additional urologic monitor-
ing. Further evaluation for renal parenchymal disease
or referral to a nephrologist should be considered if
hematuria persists and either hypertension, protein-
uria, or evidence of glomerular bleeding (RBC casts
or dysmorphic RBCs) develops.
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