In a paper published in Annals of Internal Medicine, the American College of Physicians (ACP) issued High Value Care advice for the evaluation of blood in the urine, or hematuria, as a sign of urinary tract cancer and to help physicians make decisions about referral of patients for urological assessment.
“Physicians should be aware of risk factors for cancer when considering the finding of hematuria,” said ACP President Dr. Wayne J. Riley. “Doctors and patients need to know that visible blood in the urine, or gross hematuria, is strongly associated with cancer and other potentially serious underlying conditions.”
While there is little controversy regarding the indication for urologic evaluation for patients with gross hematuria, ACP explains in the paper, the evaluation of patients with the much more common finding of microscopic hematuria is complicated by a lack of clarity regarding indications for referral and optimal components of the evaluation.
ACP advises that physicians should include gross hematuria in their routine patient history review and specifically ask all patients with microscopic hematuria about any history of gross hematuria. Physicians should refer for further urologic evaluation all adults with gross hematuria, even if self-limited (ceases with or without specific treatment). Emerging evidence suggests that a history of self-limited gross hematuria may be a common, important, and significantly underreported symptom.
Physicians should confirm heme-positive results of dipstick testing with microscopic urinalysis that demonstrates 3 or more erythrocytes/HPF (high-powered field) before initiating further evaluation in all asymptomatic adults.
Physicians should consider urology referral for cystoscopy and imaging in adults with microscopically confirmed hematuria in the absence of demonstrable benign cause. Physicians should pursue a full evaluation of hematuria even if the patient is on antiplatelet or anticoagulant therapy.
Physicians should not use screening urinalysis for cancer detection in asymptomatic adults or obtain urinary cytology or other urine-based molecular markers for bladder cancer detection in the initial evaluation of hematuria.