Microscopic Hematuria in Adults: Updated Recommendations from the American Urological Association (2024)

Key Points for Practice

• Consider repeating urinalysis in women found to have microscopic hematuria associated with UTI following successful treatment.

• With microscopic hematuria in patients at low risk of cancer, performing repeat urinalysis at six months is a reasonable alternative to imaging and cystoscopy.

• Although gross hematuria is strongly associated with malignancy, microscopic hematuria is more common and has a lower malignancy risk.

From the AFP Editors

Previous guidelines from the American Urological Association (AUA) recommended that all patients with microscopic hematuria be fully evaluated for urinary tract cancer without regard to the patient's risk of malignancy. Although this strategy results in the fewest missed cancers in modeling studies, it is costly, increases patient risk, and can result in overdiagnosis. The AUA released an updated guideline for risk-based evaluation of microscopic hematuria.

Defining Microscopic Hematuria

The AUA defines microscopic hematuria as three or more red blood cells per high-power field (RBC/HPF) on urine microscopy. A threshold between three and 10 RBC/HPF has the highest sensitivity for detecting bladder cancer and the lowest negative likelihood ratio. A single urinalysis is sufficient because 95% of microscopic hematuria is detected in one sample. Because at least 20% of positive dipstick tests for blood have no red blood cells on subsequent urine microscopy, any positive dipstick should be confirmed.

Initial Evaluation

Initial evaluation for patients with microscopic hematuria involves searching for a likely cause to be addressed. Common causes include urinary tract infections (UTIs), menstruation, external genital lesions, vagin*l atrophy, pelvic organ prolapse, urolithiasis, benign prostatic enlargement, and urethral stricture. After addressing any of these issues, a repeat urinalysis should be performed. With conditions such as prostatic hypertrophy, vagin*l atrophy, and pelvic organ prolapse, microscopic hematuria may not completely resolve. In these cases, full evaluation may be warranted. Obtaining a catheter urine sample also may be helpful.

Women with urologic malignancies are often treated repeatedly for UTI before cancer is diagnosed. Repeating urinalysis with microscopy after identifying hematuria associated with UTI should be considered, although this strategy has not been prospectively validated.

Anticoagulation does not appear to explain microscopic hematuria, and the appropriate workup should be performed in these patients. Patients taking antithrombotic medications are more likely to be diagnosed with bladder cancer, suggesting these medications may increase bleeding from underlying malignancies.

Risk Stratification

If the initial evaluation suggests no obvious source of microscopic hematuria, possible risk factors should be assessed. Smoking, higher numbers of RBC/HPF, persistent hematuria, and history of gross hematuria increase the risk of malignancy (Table 1).

Microscopic Hematuria in Adults: Updated Recommendations from the American Urological Association (1)
Low (patient meets all criteria)
Men age < 40 years; women age < 50 years
3 to 10 RBC/HPF on a single urinalysis
Never smoker or < 10 pack-years
No risk factors for urothelial cancer
Intermediate (patient meets any one of these criteria)
Men age 40 to 59 years; women age 50 to 59 years
11 to 25 RBC/HPF on a single urinalysis
10 to 30 pack-years
Low-risk patient with no prior evaluation and 3 to 10 RBC/HPF on repeat urinalysis
Additional risk factors for urothelial cancer
High (patient meets any one of these criteria)
Women or men age 60 years
> 25 RBC/HPF on a single urinalysis
> 30 pack-years
History of gross hematuria

The AUA risk categories combine factors from two validated risk scores. These risk categories have not been prospectively validated, and no prospective evidence demonstrates the clinical outcomes of using them for risk scoring.

Less common risk factors for urinary tract cancer include a family history of cancer or cancer-related syndromes, occupational exposure to benzene or aromatic amines, previous pelvic radiation therapy, previous cyclophosphamide chemotherapy, or chronic indwelling catheter or foreign body. Irritative urinary symptoms without UTI suggest increased cancer risk. With no evidence to guide evaluation, the AUA recommends considering a full evaluation in these cases.


Patients at low risk include men younger than 40 years and women younger than 50 years with microscopic hematuria between three and 10 RBC/HPF. Low-risk patients have less than a 10 pack-year smoking history and no other risk factors. The AUA recommends repeating urinalysis in six months, although an evaluation with cystoscopy and renal ultrasonography is also reasonable.


Patients at intermediate risk have at least one risk factor that takes them out of the low-risk category, such as ages 40 to 59 years in men and 50 to 59 years in women, a 10 to 30 pack-year smoking history, 11 to 25 RBC/HPF on microscopic urinalysis, and persistent microscopic hematuria after an initial low-risk determination.

For these patients, the guideline recommends cystoscopy and renal ultrasonography. Renal ultrasonography is recommended over computed tomography urography because of reasonable discrimination of cortical lesions, decreased expense, and lack of ionizing radiation. The drawback of renal ultrasonography is poor sensitivity for upper urinary tract cancers.


Patients at high risk have at least one high-risk factor, including age 60 years or older, more than a 30 pack-year smoking history, more than 25 RBC/HPF on microscopic urinalysis, and a history of gross hematuria. For these patients, the guideline recommends cystoscopy and computed tomography urography. Magnetic resonance urography and retrograde pyelography with renal imaging are reasonable if contrast media is contraindicated because of kidney disease or allergy.

After a Negative Evaluation

Based on limited study, malignancy risk is low in patients with a negative microscopic hematuria evaluation. Over 14 years of follow-up of 258 patients, only two bladder cancers were diagnosed. Repeat urinalysis within 12 months of the negative workup should be considered, and evaluation may be discontinued if no microscopic hematuria is found. The benefits of additional evaluation for recurrent microscopic hematuria are unclear.

Urine cytology and urine-based tumor marker testing should be avoided in the initial evaluation of microscopic hematuria. Positive cytology has a 10% false-positive rate and rarely leads to a bladder cancer diagnosis after negative cystoscopy. The role of cytology in the evaluation of persistent microscopic hematuria is unknown.

The views expressed are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Uniformed Services University of the Health Sciences, Department of Defense, or the U.S. government.

Editor's Note: The updated guideline is important because it provides a framework for risk stratification and targeted evaluation. If this framework had been prospectively validated, it would be more useful. The AUA combined risk factors from two validated risk scores to propose three risk levels and evaluation paradigms. The AUA acknowledges the need for validation of the guideline.

The guideline does contain an important warning: the need to consider a microscopic hematuria evaluation in patients with recurrent UTI, especially with negative culture results. About one in 10 women and one in 20 men with bladder cancer receive more than three antibiotic courses for UTI before cancer is diagnosed.

The recommendation to repeat urinalysis after six months in patients at low risk and within a year after a negative workup might be controversial in primary care. Because the future laboratory evaluations are often missed by patients, the shaky evidence behind this recommendation is concerning. The AUA cites a single study showing a slightly higher malignancy rate in patients with persistent microscopic hematuria, yet most of these patients were diagnosed with malignancy following a UTI.1 Without more evidence, it may be more important to perform a repeat urinalysis after resolution of UTI symptoms rather than a six-month repeat in all patients.—Michael J. Arnold, MD, Contributing Editor


1. Ghandour R, Freifeld Y, Singla N, et al. Evaluation of hematuria in a large public health care system. Bladder Cancer. 2019;5(2):119–129.

Guideline source: American Urological Association

Evidence rating system used? Yes

Systematic literature search described? Yes

Guideline developed by participants without relevant financial ties to industry? No

Recommendations based on patient-oriented outcomes? No

Published source:J Urol. October 2020;204(4): 778–786

Microscopic Hematuria in Adults: Updated Recommendations from the American Urological Association (2024)


How concerned should I be about microscopic hematuria? ›

Even though having blood in your urine may sound scary, microhematuria doesn't always mean that something serious is going on. It may clear up on its own, or it may be the result of something that can be treated easily. This is something best determined by working with your healthcare provider.

What is the American Urology Association definition of microscopic hematuria? ›

The AUA defines microscopic hematuria as three or more red blood cells per high-power field (RBC/HPF) on urine microscopy. A threshold between three and 10 RBC/HPF has the highest sensitivity for detecting bladder cancer and the lowest negative likelihood ratio.

What is the new AUA hematuria guideline? ›

The new 2020 AUA Guideline provides an individualized, risk-stratified approach to hematuria evaluation based on the patient's risk of harboring a urinary tract cancer. Nielsen's work in this area started with a collaboration with the American College of Physicians' High Value Care Task Force, published in 2016.

What is the normal range for microscopic hematuria? ›

Normally, less than 2 RBCs/hpf are observed. Microscopic hematuria is defined as the presence of 3 RBCs/hpf or more in 2 of 3 urine samples. Hematuria may also be transient or persistent.

How long does it take for microscopic hematuria to go away? ›

Expected duration of hematuria

For example, hematuria related to strenuous exercise typically goes away on its own within 24 to 48 hours. Hematuria resulting from a urinary tract infection will end when the infection is cured. Hematuria related to a kidney stone will clear after the stone is passed or removed.

What percentage of people have microscopic hematuria? ›

Hematuria can be either grossly visible (macrohematuria) or only detectable under a microscope (microhematuria). Microhematuria is often asymptomatic and has a prevalence of 4–5% in routine clinical practice. It may be due to an underlying disease of the kidneys or the urogenital tract.

When is microscopic haematuria significant? ›

Microscopic hematuria, a common finding on routine urinalysis of adults, is clinically significant when three to five red blood cells per high-power field are visible.

What cancers cause microscopic hematuria? ›

The most likely cancer is bladder cancer, although the blood also could be a sign or kidney cancer (renal cell cancer) or prostate cancer. Blood in the urine is more likely to be cancer in men than in women, mainly because men develop bladder cancer at a much higher rate — about four times as much — than women.

What does urologist do for hematuria? ›

A physical exam, personal and family history review, and variety of tests may be done to pinpoint the cause of hematuria. These include urinalysis, blood tests, imaging tests, and cystoscopy, which is the use of a tiny fiberoptic camera to visualize the bladder. Sometimes the cause cannot be determined.

What is the gold standard for diagnosis of hematuria? ›

Kidney biopsy: The gold standard to diagnose a glomerular cause of hematuria is a kidney biopsy by a nephrologist or interventional radiologist. [5] The presence of dysmorphic RBCs and RBC casts should be followed by a kidney biopsy.

What are the four 4 different categories of hematuria? ›

Hematuria may be categorized as follows:
  • Gross hematuria.
  • Microscopic hematuria with clinical symptoms.
  • Asymptomatic microscopic hematuria with proteinuria.
  • Asymptomatic microscopic (isolated) hematuria.
Feb 29, 2024

What is the best scan for hematuria? ›

The prominence of the role of excretory urography in the evaluation of patients with hematuria has diminished, and MDCT urography is now preferred to excretory urography in most cases.

Should I be worried about microscopic hematuria? ›

Although seeing blood in the urine can be frightening, most of the time hematuria is not life threatening. However, it is important to investigate the cause of hematuria because, occasionally, it is caused by a serious condition.

What is the cutoff for microscopic hematuria? ›

The definition of microscopic hematuria varies from one to more than 10 red blood cells per high-power field on urine microscopy, with trade-offs in sensitivity and specificity for diagnosing serious underlying disease. The review authors advocate a cutoff of two or more red cells per field for the diagnosis.

Can you have blood in your urine and nothing be wrong? ›

In many cases, the cause is harmless. But blood in urine also can be a sign of a serious illness. If you can see the blood, it's called gross hematuria. Blood that can't be seen with the naked eye is called microscopic hematuria.

How much blood in urine is worrisome? ›

Either way, if you see something, even once, make an appointment. Then there's microscopic hematuria, which is what it sounds like—blood that's only visible under a microscope. Anything over three or four red blood cells is considered abnormal.

What level of RBC in urine is concerning? ›

Normal Results

A normal result is 4 red blood cells per high power field (RBC/HPF) or less when the sample is examined under a microscope. The example above is a common measurement for a result of this test. Normal value ranges may vary slightly among different laboratories.

Top Articles
Latest Posts
Article information

Author: Delena Feil

Last Updated:

Views: 6299

Rating: 4.4 / 5 (65 voted)

Reviews: 88% of readers found this page helpful

Author information

Name: Delena Feil

Birthday: 1998-08-29

Address: 747 Lubowitz Run, Sidmouth, HI 90646-5543

Phone: +99513241752844

Job: Design Supervisor

Hobby: Digital arts, Lacemaking, Air sports, Running, Scouting, Shooting, Puzzles

Introduction: My name is Delena Feil, I am a clean, splendid, calm, fancy, jolly, bright, faithful person who loves writing and wants to share my knowledge and understanding with you.