Microscopic Hematuria

Approach

Microscopic hematuria definition: Appropriately collected void with

  • 3 or more RBCs per high-powered field

  • No evidence of infection

Evaluation

  • “Dirty sample,” e.g. > 3 bacteria species and/or multiple squamous cells: Repeat U/A

  • Urinalysis suggestive of UTI, e.g. positive leukocyte esterase +/- nitrites: Treat UTI

  • Patient menstruating or other reasonable explanation (e.g. calcium oxalate crystals on U/A, recent history of vigorous exercise/trauma): Repeat U/A in 6 weeks

  • Age > 35 years: Refer to urology for cystoscopy if any of the following apply

    • No alternative explanation, e.g. exercise, trauma, illness, infection

    • Patient has any risk factors for urinary malignancy, e.g. excessive NSAID use, smoking, exposure to chemical dyes

  • Consider referral to nephrology for any the following findings on urinalysis:

    • Proteinuria in the setting of DM, HTN, and/or elevated creatinine levels

    • Presents of albumin and/or cellular casts

AAFP Algorithm for Asymptomatic Microhematuria (2013)

Differential

Pyuria