© The Canadian Journal of Urology™; 21(Supplement 2); June 2014
Microscopic hematuria
It is quite common for a physician
to detect RBCs in a microscopic
urinanalysis or for the the all-
pervasive urine dipstick to be
positive for RBCs. It is imporant
to determine if the hematuria is
significant. Studies have defined
significant hematuria as at least
8 RBCs/high power field (HPF)
in a microscopic urinalysis or a
least a moderate (2+) reading for
blood on a urine dipstick. If the
patient is older than 40 years old
and smokes, then 5 RBCs/HPF
might be considered significant.
1
See Figure 1.
Macroscopic hematuria
After finding macroscopic (also
called “visible” or “gross”)
hematuria, the physician needs
Gross hematuria with pain on one side usually
indicates colic, which suggests that the patient is
passing of a ureteric stone or there is bleeding from a
lesion on that side.
Microscopic
< 40 years old
> 40 years old
Smoker
Non smoker
> 5 RBC/HPF
> 8 RBC/HPF
Cytology
Renal ultrasound
KUB
Microscopic Hematuria Algorithm
Smoker
Non smoker
< 8 RBC/HPF
Follow up
> 8 RBC/HPF
Referral for
cystoscopy
HPF = high-power eld; KUB = kidney, ureter, and bladder; RBC = red blood cell
Figure 1.
Algorithm for the evaluation of microscopic hematuria.
Hx of trauma
Vigorous exercise
Menses
Foods (eg beets),
dyes, meds
Yes
Gross Hematuria Algorithm
No
Repeat 1 week
after hematuria
clears
Urinalysis
Pos blood- Microscopic
hematuria work up
Cytology
Pos- Referral
Negative
No treatment
Urinalysis
Signs of renal
disease
Casts/Protein
Signs of
infection
No renal or
infection signs
Referral
Citology
& referral
Woman
NO fever
Woman
fever
Man
(fever or not)
Treat
antibiotics
Antibiotics
Antibiotics
Repeat urine
3 weeks
Clear
Normal
Referral
for cysto
Positive
Follow
Work up
Ultrasound
and KUB
Ultrasound
and KUB
Abnormal
Referral
KUB= kidney, ureter, and bladder
Figure 2.
Algorithm for the evaluation of gross hematuria.
to determine if the patient has any pain, if the
hematuria is in the initial, entire, or final part of the
urine stream, and whether the patient has any blood
clots.
If gross hematuria occurs
throughout the urine stream and
the pain is specifically in the
pelvis, this suggests hemoragic
cystitis, acute bacterial prostatitis, a
bladder tumor, or a bladder stone.
Based on the anatomy of the
urinary tract and the authors’
clinical experience, hematuria
throughout the urine stream
indicates bleeding from above
the bladder neck. Hematuria
only in the initial part of the urine
stream suggests bleeding from
the urethra, whereas hematuria
only at the end of the urine
stream suggests bleeding from
the prostate or bladder neck.
Patient work up
Finding significantmicroscopic or
macroscopic hematuria requires
a work up. See Figures 1 and 2.
If the patient only has pelvic
pain and gross hematuria,
antibiotics are usually given as
first-line therapy. The clinician
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Barkin ET AL.
