Publication Date: July 23, 2020

Guideline Statements

Diagnosis and Definition of Microhematuria

Clinicians should define microhematuria as ≥3 red blood cells per high-power field on microscopic evaluation of a single, properly collected urine specimen. (Standard, C)
Clinicians should not define microhematuria by positive dipstick testing alone. A positive urine dipstick test (trace blood or greater) should prompt formal microscopic evaluation of the urine. (StrongC)

Initial Evaluation

In patients with microhematuria, clinicians should perform a history and physical examination to assess risk factors for genitourinary malignancy, medical renal disease, gynecologic and non-malignant genitourinary causes of microhematuria. (Clinical Principle, )
Clinicians should perform the same evaluation of patients with microhematuria who are taking antiplatelet agents or anticoagulants (regardless of the type or level of therapy) as patients not on these agents. (StrongC)
In patients with findings suggestive of a gynecologic or non-malignant urologic etiology, clinicians should evaluate the patients with appropriate physical examination techniques and tests to identify such an etiology. (Clinical Principle, )
In patients diagnosed with gynecologic or non-malignant genitourinary sources of microhematuria, clinicians should repeat urinalysis following resolution of the gynecologic or non-malignant genitourinary cause. If microhematuria persists or the etiology cannot be identified, clinicians should perform risk-based urologic evaluation. (Clinical Principle, )
In patients with hematuria attributed to a urinary tract infection, clinicians should obtain a urinalysis with microscopic evaluation following treatment to ensure resolution of the hematuria. (StrongC)
Clinicians should refer patients with microhematuria for nephrologic evaluation if medical renal disease is suspected. However, risk-based urologic evaluation should still be performed. (Clinical Principle, )

Risk Stratification

Following initial evaluation, clinicians should categorize patients presenting with microhematuria as low-, intermediate-, or high-risk for genitourinary malignancy. (Standard, C)

Urinary Tract Evaluation


In low-risk patients with microhematuria, clinicians should engage patients in shared decision-making to decide between repeating urinalysis within six months or proceeding with cystoscopy and renal ultrasound. (Recommendation, C)

Initially Low-Risk with Hematuria on Repeat Urinalysis

Low-risk patients who initially elected not to undergo cystoscopy or upper tract imaging and who are found to have microhematuria on repeat urine testing should be reclassified as intermediate- or high-risk. In such patients, clinicians should perform cystoscopy and upper tract imaging in accordance with recommendations for these risk strata. (Standard, C)


Clinicians should perform cystoscopy and renal ultrasound in patients with microhematuria categorized as intermediate-risk for malignancy. (Standard, C)


Clinicians should perform cystoscopy and axial upper tract imaging in patients with microhematuria categorized as high-risk for malignancy. (Standard, C)
Options for Upper Tract Imaging in High-Risk Patient:
If there are no contraindications to its use, clinicians should perform multiphasic CT urography (including imaging of the urothelium). (ModerateC)
If there are contraindications to multiphasic CT urography, clinicians may utilize MR urography. (Moderate, C)
If there are contraindications to multiphasic CT urography and MR urography, clinicians may utilize retrograde pyelography in conjunction with non-contrast axial imaging or renal ultrasound. (Expert Opinion , )
Clinicians should perform white light cystoscopy in patients undergoing evaluation of the bladder for microhematuria. (ModerateC)
In patients with persistent or recurrent microhematuria previously evaluated with renal ultrasound, clinicians may perform additional imaging of the urinary tract. (ConditionalC)
In patients with microhematuria who have a family history of renal cell carcinoma or a known genetic renal tumor syndrome, clinicians should perform upper tract imaging regardless of risk category. (Expert Opinion , )

Urinary Markers

Clinicians should not use urine cytology or urine-based tumor markers in the initial evaluation of patients with microhematuria. (StrongC)
Clinicians may obtain urine cytology for patients with persistent microhematuria after a negative workup who have irritative voiding symptoms or risk factors for carcinoma in situ. (Expert Opinion , )


In patients with a negative hematuria evaluation, clinicians may obtain a repeat urinalysis within 12 months. (Option, C)
For patients with a prior negative hematuria evaluation and subsequent negative urinalysis, clinicians may discontinue further evaluation for microhematuria. (ConditionalC)
For patients with a prior negative hematuria evaluation who have persistent or recurrent microhematuria at the time of repeat urinalysis, clinicians should engage in shared decision-making regarding need for additional evaluation. (Expert Opinion , )
For patients with a prior negative hematuria evaluation who develop gross hematuria, significant increase in degree of microhematuria, or new urologic symptoms, clinicians should initiate further evaluation. (ModerateC)

Recommendation Grading





Authoring Organization

Publication Month/Year

July 23, 2020

Supplemental Implementation Tools

Document Type


External Publication Status


Country of Publication


Inclusion Criteria

Male, Female, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Diagnosis, Assessment and screening, Treatment, Management, Prevention

Diseases/Conditions (MeSH)

D006417 - Hematuria


urinary tract infection (UTI), Microhematuria, cystoscopy, hematuria

Source Citation

Barocas DA, Boorjian SA, Alvarez RD, Downs TM, Gross CP, Hamilton BD, Kobashi KC, Lipman RR, Lotan Y, Ng CK, Nielsen ME, Peterson AC, Raman JD, Smith-Bindman R, Souter LH. Microhematuria: AUA/SUFU Guideline. J Urol. 2020 Oct;204(4):778-786. doi: 10.1097/JU.0000000000001297. Epub 2020 Jul 23. PMID: 32698717.

Supplemental Methodology Resources

Methodology Supplement


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