SUMMARY: Hematuria is a common finding in clinical practice and millions of patients have routine urine evaluation. However, the magnitude of the risk for an underlying malignancy can vary significantly. Screening healthy, asymptomatic patients with urinalysis for malignancy is not currently recommended by any major health organization. This article describes the indications for the evaluation of hematuria, as a marker of occult urinary tract cancer, and is meant to help Health Care Providers make appropriate referral of patients, for urologic evaluation. The information in this article was gathered following a review of published clinical guidelines that addressed the evaluation of hematuria as a marker of occult urinary tract cancer, as well as other relevant studies, from the peer-reviewed literature. The American College of Physicians' High Value Care Task Force put this information together, with the intent to increase awareness and provide practical advice, based on the best available evidence.
High-Value Care Advice 1: Clinicians should include gross hematuria in their routine review of systems and specifically ask all patients with microscopic hematuria about any history of gross hematuria.
High-Value Care Advice 2: Clinicians should not use screening urinalysis for cancer detection in asymptomatic adults.
High-Value Care Advice 3: Clinicians should confirm heme-positive results of dipstick testing with microscopic urinalysis that demonstrates 3 or more erythrocytes per high-powered field before initiating further evaluation in all asymptomatic adults.
High-Value Care Advice 4: Clinicians should refer all adults with gross hematuria, even if self-limited, for further urologic evaluation.
High-Value Care Advice 5: Clinicians should consider urology referral for cystoscopy and imaging in adults with microscopically confirmed hematuria, in the absence of some demonstrable benign cause.
High-Value Care Advice 6: Clinicians should pursue evaluation of hematuria even if the patient is receiving antiplatelet or anticoagulant therapy.
High-Value Care Advice 7: Clinicians should not obtain urinary cytology or other urine-based molecular markers for bladder cancer detection in the initial evaluation of hematuria.
Hematuria as a Marker of Occult Urinary Tract Cancer: Advice for High-Value Care from the American College of Physicians. Nielsen M, Qaseem A, for the High Value Care Task Force of the American College of Physicians. Ann Intern Med. 2016;164:488-497.