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Evaluation of Microscopic Hematuria :

A Critical Review and Proposed Algorithm


MAT THEW A . NI EMI
AND
ROBERT A .COHEN
INTRODUCTION
Microscopic hematuria (MH), often discovered incidentally by
clinicians, can arise from anywhere along the urinary tract and
has an extensive differential diagnose benign process or
genitourinary (GU) malignant.
EPIDEMIOLOGY
MH is found in a substantial proportion of adults, although precise prevalence
estimates vary depending on:
1. Age
2. Sex,
3. and other patient characteristics.

According to 2012 American Urology Association (AUA) screening studies found


prevalence ranged from less than 3% to more than 20% among older men, men
with smoking histories, and individuals with repeated urine testing
DIFFERENTIAL DIAGNOSIS
ASSOCIATIONS WITH DISEASE
The presence of MH has been associated with the subsequent development of
even more serious kidney disease, including End Stage Renal Disease (ESRD)

Levey et al reported elevated urinary protein excretion is an established


independent risk factor for :
1. All-cause and cardiovascular mortality and nonfatal cardiovascular
2. Kidney disease; glomerular MH or malignancy disease.
Hollenbeck et al reported  hematuria among individuals aged 66 years or
older is an independent predictor bladder cancer

Kaiser et al reported  evaluation of asymptomatic MH  GU cancer was


found in 3.4% of subjects, including 100 cases of bladder cancer and 11
cases of kidney cancer.
EVALUATION STRATEGIES
Evaluation strategies and diagnostic tools can be used in MH case which are :

1. Urine Dipstick reagents


2. Microscopy morphology
3. Ultrasound-Graphy
4. Intravenous Urography (IVU)
5. Computed Tomography (CT) or CT urography
6. Magnetic Resonance Imaging (MRI) or MRI urography
7. Cystoscopic with mucosal biopsy
8. Biomarkers (underdevelopment)
EXISTING GUIDELINES AND RECOMMENDATIONS
American Urologic Association (AUA)

Single positive MH urinalysis,

Full urologic workup every 3 to 5 years

Persistent asymptomatic MH,

Individuals with MH from 35 years old to undergo cystoscopy.


RECOMMENDED APPROACH
AREAS OF UNCERTAINTY
The age threshold for performing cystoscopy to 35 in all individuals
with MH is inadequate to determine a specific age at which cystoscopy
is indicated but suggest that clinical judgment and patient preference
should be used to make decisions about using cystoscopy for those with
MH between the age of 40 and 50 years
The association between MH and the subsequent development of
more significant kidney disease has brought into question the
previously regarded “benign” nature of isolated glomerular MH to
assess for the development of kidney function changes and the
development of albuminuria or proteinuria.
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