Workup for microscopic hematuria

I'm seeing a lot of patients (mostly male) who have had microscopic hematuria on several urine specimens. After getting negative results on lab work I've submitted, referral to a urologist usually results in CT urogram and cystoscopy. When those also prove to be negative, I get a letter saying the hematuria is “likely benign” and to “monitor every so often to look for changes/increased blood in the patient's urine” but no other specific recommendations. Is there anything else I should be doing? When does the workup (imaging/cystoscopy) need to be repeated?
—Jonathan Marsh, MD, Indianapolis

Dr. Marsh asks a great practical question. The American Urological Association has issued guidelines for the evaluation of microscopic hematuria in adults that include how to manage patients following a negative workup (www.aafp.org/afp/20010315/1145.html, accessed September 15, 2008). In summary, the policy suggests urinalysis, BP, and cytology at six, 12, 24, and 36 months. If negative, then no further evaluation is needed. If hematuria, hypertension, proteinuria, or glomerular bleeding persists during that follow-up time frame, then nephrologic evaluation for primary renal disease should be considered. Finally, if gross hematuria, abnormal cytology, or irritative voiding symptoms without infection occur, repeat urologic workup should be performed.
—David T. Noyes, MD (120-2)

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