Guidelines on Hematuria: First-line Evaluation

The American Urological Association (AUA) published guidelines for asymptomatic microhematuria. The document includes 19 guidelines with recommendation levels ranging from A to C (high to low) and some expert opinion recommendations included. The full guidelines can be accessed at http://www.auanet.org/common/pdf/education/clinical-guidance/Asymptomatic-Microhematuria.pdf.

Q: I am studying for my boards and am deep into the renal/urology section. I graduated so long ago that IVPs were the evaluation of choice. What is the “expert opinion” now on managing the patient with hematuria? Do we go straight to cystoscopy or use a different test?

First-line evaluation for asymptomatic microscopic hematuria now requires CT urography instead of IV pyelography (IVP) or cystoscopy (see AUA guideline 10). ¹ The CT should be done with and without IV contrast and be multiphasic in nature. Specific high-resolution evaluation of the urothelium of the upper urinary tracts during the excretory phase must be included. This is the most sensitive and specific radiologic examination to adequately evaluate for a renal mass in the parenchyma as well as for abnormalities in the upper tracts simultaneously. ¹

Using contrast dye in a patient with decreased renal function is always problematic. Precautions to be taken include withholding ACE inhibitors and angiotensin receptor blockers before and after the procedure and hydrating the patient before, during, and after administration of contrast dye.

Sarah Sparks, NP , St. Luke’s Clinic–Nephrology, St. Luke’s Health System, Boise, ID

References
1. Davis R, Jones JS, Barocas DA, et al; American Urological Association. Diagnosis, Evaluation, and Follow-up of Asymptomatic Microhematuria (AMH) in Adults: AUA Guideline. Linthicum, MD: American Urological Association Education and Research, Inc; 2012. http://www.auanet.org/common/pdf/education/clinical-guidance/Asymptomatic-Microhematuria.pdf. Accessed January 24, 2013.
2. National Kidney and Urologic Diseases Information Clearinghouse. Hematuria: blood in the urine (2012). http://kidney.niddk.nih.gov/kudiseases/pubs/hematuria. Accessed January 17, 2013.
3. Geavlete B, Jecu M, Multescu R, et al. HAL blue-light cystoscopy in high-risk nonmuscle-invasive bladder cancer: re-TURBT recurrence rates in a prospective, randomized study. Urology. 2010;76(3):664-669.

Suggested Reading
Feldman AS, Hsu C-Y, Kurtz M, Cho KC. Etiology and evaluation of hematuria in adults (2012). www.uptodate.com/contents/etiology-and-evaluation-of-hematuria-in-adults. Accessed January 17, 2013.
Jayne D. Hematuria and proteinuria. In: Greenberg A, ed; National Kidney Foundation. Primer on Kidney Diseases . 5th ed. Saunders; 2009:33-42.