Dignosis, Evaluation and Follow-up of Asymptomatic Microhematuria (AMH) in Adults

Publication Date: December 1, 2012
Last Updated: March 14, 2022

Recommendations

1. AMH is defined as three or greater RBCs per high powered field on a properly collected urinary specimen in the absence of an obvious benign cause. A positive dipstick does not define AMH, and evaluation should be based solely on findings from microscopic examination of urinary sediment and not on a dipstick reading. A positive dipstick reading merits microscopic examination to confirm or refute the diagnosis of AMH. (Expert Opinion , )
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2. The assessment of the AMH patient should include a careful history, physical examination and laboratory examination to rule out benign causes of AMH such as infection, menstruation, vigorous exercise, medical renal disease, viral illness, trauma or recent urological procedures. (Clinical Principle, )
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3. Once benign causes have been ruled out, the presence of AMH should prompt a urologic evaluation. (, C)
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4. At the initial evaluation, an estimate of renal function should be obtained (may include calculated eGRF, creatinine and BUN) because intrinsic renal disease may have implications for renal-related risk during the evaluation and management of patients with AMH. (Clinical Principle, )
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5. The presence of dysmorphic RBCs, proteinuria, cellular casts and/or renal insufficiency or any other clinical indicator suspicious for renal parenchymal disease warrants concurrent nephrologic work-up but does not preclude the need for urologic evaluation. (, C)
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6. MH that occurs in patients who are taking anti-coagulants requires urologic evaluation and nephrologic evaluation regardless of the type or level of anti-coagulation therapy. (, C)
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7. For the urologic evaluation of AMH, cystoscopy should be performed on all patients aged 35 years and older. (, C)
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8. In patients younger than age 35 years, cystoscopy may be performed at the physician's discretion. (, C)
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9. Cystoscopy should be performed on all patients who present with risk factors for urinary tract malignancies (e.g., irritative voiding symptoms, current or past tobacco use, chemical exposures), regardless of age. (Clinical Principle, )
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10. The initial evaluation for AMH should include a radiologic evaluation. Multi-phasic CTU (without and with intravenous contrast), including sufficient phases to evaluate the renal parenchyma to rule out a renal mass and an excretory phase to evaluate the urothelium of the upper tracts, is the imaging procedure of choice because it has the highest sensitivity and specificity for imaging the upper tracts. (, C)
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11. For patients with relative or absolute contraindications that preclude use of multi-phasic CT (such as renal insufficiency, contrast allergy, pregnancy), MRU (without/with IV contrast) is an acceptable alternative imaging approach. (, C)
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12. For patients with relative or absolute contraindications that preclude use of multiphase CT (such as renal insufficiency, contrast allergy, pregnancy) where collecting system detail is deemed imperative, combining MRI with retrograde pyelograms (RPGs) provides alternative evaluation of the entire upper tracts. (Expert Opinion , )
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13. For patients with relative or absolute contraindications that preclude use of multi-phasic CT (such as renal insufficiency, contrast allergy) and MRI (presence of metal in the body) where collecting system detail is deemed imperative, combining non-contrast CT or renal US with RPGs provides alternative evaluation of the entire upper tracts. (Expert Opinion , )
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14. The use of urine cytology and urine markers (NMP22®, BTA stat® and UroVysion® FISH) is NOT recommended as a part of the routine evaluation of the AMH patient. (, C)
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15. In patients with persistent MH following a negative work-up or those with other risk factors for carcinoma in situ (e.g., irritative voiding symptoms, current or past tobacco use, chemical exposures), cytology may be useful. (, C)
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16. Blue light cystoscopy should NOT be used in the evaluation of patients with AMH. (, C)
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17. If a patient with a history of persistent AMH has two consecutive negative annual urinalyses (one per year for two years from the time of initial evaluation or beyond), then no further urinalyses for the purpose of evaluation of AMH are necessary. (Expert Opinion , )
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18. For persistent AMH after negative urologic work-up, yearly urinalyses should be conducted. (, C)
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19. For persistent or recurrent AMH after initial negative urologic work-up, repeat evaluation within three to five years should be considered. (Expert Opinion , )
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Recommendation Grading

Disclaimer

Overview

Title

Dignosis, Evaluation and Follow-up of Asymptomatic Microhematuria (AMH) in Adults

Authoring Organization

Publication Month/Year

December 1, 2012

Last Updated Month/Year

May 16, 2023

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The purpose of this guideline is to provide a clinical framework for the diagnosis, evaluation and follow-up of asymptomatic microhematuria.

Inclusion Criteria

Female, Male, Adult

Health Care Settings

Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Management, Treatment

Diseases/Conditions (MeSH)

D006417 - Hematuria

Keywords

hematuria, urogenital neoplasms, urinalysis, Microhematuria

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
132
Literature Search Start Date
January 1, 2010
Literature Search End Date
December 1, 2019