EVALUATION OF ASYMPTOMATIC MICROSCOPIC HEMATURIA IN ADULTS: THE AMERICAN UROLOGICAL ASSOCIATION BEST PRACTICE POLICY—PART II: PATIENT EVALUATION, CYTOLOGY, VOIDED MARKERS, IMAGING, CYSTOSCOPY, NEPHROLOGY EVALUATION, AND FOLLOW-UP GARY D. GROSSFELD, MARK S. LITWIN, J. STUART WOLF, JR, HEDVIG HRICAK, CATHRYN L. SHULER, DAVID C. AGERTER, AND PETER R. CARROLL P art I of this report (preceding article) addressed the definition, detection, prevalence, and etiol- ogy of asymptomatic microscopic hematuria. This section of the best practice policy (Part II) is intended to serve as guidance to urologists and primary care physicians with respect to the evaluation of adult pa- tients who may have asymptomatic microscopic hematuria. Recommendations for a nephrology evaluation and for patient follow-up are provided. PATIENT EVALUATION Patients with microscopic hematuria accompa- nied by significant proteinuria, red blood cell (RBC) casts, dysmorphic RBCs on microscopic analysis of the urinary sediment, or an elevated serum creatinine level should first undergo a gen- eral medical evaluation or evaluation for the pres- ence of primary renal disease (see the section In- dications for Nephrology Evaluation). Patients without these findings and those with risk factors for significant urologic disease (Table I) should be promptly referred for a urologic evaluation. The initial patient evaluation should include a careful history and physical examination. Physical examination in the woman should include a ure- thral and vaginal examination to exclude any local causes of microscopic hematuria. A catheterized urinary specimen is indicated if a clean catch spec- imen cannot be reliably obtained (ie, evidence of vaginal contamination on microscopic examina- tion or obese patients). In uncircumcised men, the foreskin should be retracted to expose the glans penis, if possible. If a phimosis is present, a cathe- terized urinary specimen may be required. The laboratory analysis begins with a compre- hensive examination of the urine and urinary sed- iment. The number of RBCs per high-powered field should be determined. In addition, the presence of dysmorphic RBCs (see below) or RBC casts should be noted. The urine should also be tested for the presence and degree of proteinuria and any evi- dence of urinary tract infection. The serum creati- nine level should be measured. The remaining lab- oratory investigation should be guided by any specific findings on the history, physical examina- tion, and urinalysis. A complete urologic evalua- tion of microscopic hematuria also includes radio- logic imaging of the upper urinary tracts followed by cystoscopic examination of the urinary bladder. In some cases, cytologic evaluation of exfoliated cells in the voided urine specimen may also be performed (see the next section). Patients in whom a carefully performed history suggests a “benign” cause of their microscopic he- maturia—such as menstruation, recent vigorous exercise, sexual activity, viral illness, or trauma— should undergo a repeated urinalysis 48 hours af- ter cessation of these activities. 1 Should the re- peated urinalysis be negative for hematuria, no From the Department of Urology, University of California School of Medicine, San Francisco and Program in Urologic Oncology, University of California San Francisco/Mount Zion Comprehen- sive Care Center, San Francisco, California; Departments of Urology and Health Services, University of California, Los Angeles, Schools of Medicine and Public Health, Los Angeles, California; Department of Surgery (Urology), University of Michigan School of Medicine, Ann Arbor, Michigan; Memorial Sloan-Kettering Cancer Center, New York, New York; Department of Medicine, Di- vision of Nephrology, Oregon Health Sciences University, Portland, Oregon; and Department of Family Medicine, Mayo Medical School and Mayo Clinic Rochester, Rochester, Minnesota Reprint requests: Gary Grossfeld, M.D., c/o Carol Schwartz, M.P.H., R.D., Guidelines Manager, American Urological Associ- ation, 1120 North Charles Street, Baltimore, MD 21201-5559 Submitted: October 5, 2000, accepted (with revisions): Decem- ber 14, 2000 UPDATE © 2001, ELSEVIER SCIENCE INC. UROLOGY 57: 604 – 610, 2001 • 0090-4295/01/$20.00 604 ALL RIGHTS RESERVED PII S0090-4295(01)00920-7