Today we’re going to take a look at the 10 key changes found within the American Urological Association (AUA) clinical practice guidelines for microhematuria. Microhematuria is a condition where blood is present in the urine, though it may not be visible to the naked eye. The guideline was recently updated on February 27, 2025, which reaffirms and refreshes the previous guideline from October 2020.
Guidelines Referenced
Change 1
Recommendation 3 was updated slightly to include additional details. It now specifically refers to cover the following factors during the initial evaluation for microhematuria:
- blood pressure measurement
- serum creatinine
- detailed smoking history
Change 2
There were a handful of updates to the AUA Microhematuria Risk Stratification System, which includes a clearer presentation, a couple small definition adjustments, and a few as changes specific to ages in women. A comparison table is provided below:
| 2025 | 2020 | 2025 | 2020 | 2025 | 2020 | |
|---|---|---|---|---|---|---|
| Risk of Malignancy* | Low/Negligible (0-0.4%) | Low | Intermediate (0.2-3.1%) | Intermediate | High (1.3-6.3%) | High |
| Number of criteria patient must meet | All | One or more | One or more | |||
| Degree of hematuria on a single urinalysis | 3-10 RBC/HPF+ | 11-25 RBC/HPF+ | >25 RBC/HPF+ | |||
| Alternative criteria for degree of hematuria | N/A | Previously low/negligible-risk patient with no prior evaluation and 3-25 RBC/HPF* on repeat urinalysis | Low-risk patient with no prior evaluation and 3-10 RBC/HPF on repeat urinalysis | History of gross hematuria | ||
| Age for women | <60 years | <50 years | ≥60 years | 50-59 years | Women should not be categorized as high risk solely based on age | ≥60 years |
| Age for men | <40 years | 40-59 years | ≥60 years | |||
| Smoking history | Never smoker or <10 pack years | 10-30 pack years | >30 pack years | |||
| Presence of additional risk factors for urothelial cancer | None | Any | One or more plus any high-risk feature | Not addressed | ||
Change 3
Recommendations 10 and 11 were both updated, including the wording going from low risk to low/negligible risk, as well as the details of each recommendation, which are compared below.
| Risk Evaluation | 2025 | 2020 |
|---|---|---|
| Low/Negligible Risk | In low/negligible-risk patients with microhematuria, clinicians should obtain repeat urinalysis within six months rather than perform immediate cystoscopy or imaging. | In low-risk patients with microhematuria, clinicians should engage patients in shared decision-making to decide between repeating UA within six months or proceeding with cystoscopy and renal ultrasound. |
| Initially low/negligible risk with hematuria on repeat urinalysis | Low/negligible-risk patients with microhematuria on repeat urinalysis should be reclassified as intermediate- or high-risk based on repeat urinalysis. In such patients, clinicians should perform risk-based evaluation in accordance with recommendations for these respective risk strata. | 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. |
Change 4
Two new recommendations were added for intermediate risk evaluation.
- In appropriately counseled intermediate-risk patients who want to avoid cystoscopy and accept the risk of forgoing direct visual inspection of the bladder urothelium, clinicians may offer urine cytology or validated urine-based tumor markers (Table 5) to facilitate the decision regarding utility of cystoscopy. Renal and bladder ultrasound should still be performed in these cases.
- For patients with intermediate-risk microhematuria who do not undergo cystoscopy based on urinary marker results, clinicians should obtain a repeat urinalysis within 12 months. Such patients with persistent microhematuria should undergo cystoscopy.
Change 5
One new recommendation was added for high-risk evaluation:
- Clinicians should perform cystoscopy and axial upper tract imaging in patients with microhematuria categorized as high-risk for malignancy.
Change 6
Additional details were added to the evaluation of patients with high risk and a family history of renal cell carcinoma:
| Risk Evaluation | 2025 | 2020 |
|---|---|---|
| High risk and family history of RCC | In patients with microhematuria who have a family history of renal cell carcinoma, a known genetic renal tumor syndrome, or a personal or family history of (or suspicious for) Lynch syndrome, clinicians should perform upper tract imaging regardless of risk category. | In patients with microhematuria who have a family history of renal cell carcinoma (RCC) or a known genetic renal tumor syndrome, clinicians should perform upper tract imaging regardless of risk category. |
Change 7
The recommendation for routine use of urine cytology or urine-based tumor markers for cystoscopy in the initial evaluation has been updated:
| Urinary Markers | 2025 | 2020 |
|---|---|---|
| Urine cytology or urine-based tumor markers for cystoscopy | Clinicians should not routinely use urine cytology or urine-based tumor markers to decide whether to perform cystoscopy in the initial evaluation of low/negligible- or high-risk patients with microhematuria. | Clinicians should not use urine cytology or urine-based tumor markers in the initial evaluation of patients with microhematuria. |
Change 8
One new recommendation was added for routine use of cytology or urine-based tumor markers
- Clinicians should not routinely use cytology or urine-based tumor markers as adjunctive tests in the setting of a normal cystoscopy.
Change 9
The recommendation has been updated for the use of urine cytology for certain patients with persistent microhematuria:
| Urinary Markers | 2025 | 2020 |
|---|---|---|
| Patients with persistent microhematuria | Clinicians may obtain urine cytology for high-risk patients with equivocal findings on cystoscopic evaluation or those with persistent microhematuria and irritative voiding symptoms or risk factors for carcinoma in situ after a negative workup. | 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. |
Change 10
The follow up recommendationsIn for repeat urinalysis has changed for patients with a negative hematuria evaluation. The strength of the recommendations has also increased from “conditional” to “strong”.
| Follow Up | 2025 | 2020 |
|---|---|---|
| Patients with a negative hematuria evaluation | In patients with a negative risk-based hematuria evaluation, clinicians should engage in shared decision-making regarding whether to repeat urinalysis in the future. (Strong) | In patients with a negative hematuria evaluation, clinicians may obtain a repeat urine analysis within 12 months. (Conditional) |
There you have it! This concludes our Guidelines Timelines Series post covering the American Urological Association Clinical Guidelines for Microhematuria. Let us know if you would like to see a similar Guidelines Timelines article for another society and topic!
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