GYN

CMECNE

ACOG and AUGS Guidance: Asymptomatic Microscopic Hematuria in Women

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Incorporate appropriate urine sample collection into care
2. List appropriate criteria where no further evaluation for hematuria is required because of a low risk of malignancy

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Jan 25 2023, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

SUMMARY:

ACOG and AUGS released joint guidance on the screening and management of asymptomatic microscopic hematuria in women. The data suggests that women at low risk for urinary tract malignancy (bladder, ureter and kidney) do not necessarily need follow up for asymptomatic microscopic hematuria.

Sample Collection

Positive dipstick does not define asymptomatic microscopic hematuria but should generate a urinalysis and microscopic examination of urinary sediment
A voided midstream sample is the recommended collection method for diagnosis
Women have sex-specific risks for contamination (false positives) due to the following conditions
- Menstruation
- Urogenital atrophy
- Pelvic organ prolapse

ACOG & AUGS

No further evaluation required for low risk women that meet the following criteria (risk of malignancy ≤ 0.5%)
- Asymptomatic
- Never-smoking
- Age 35 to 50
- ≤ 25 red blood cells per high-power field
As part of the Choosing Wisely Campaign (2020), AUGS continues to support limiting interventions and states

Asymptomatic hematuria in women is common but less likely to be associated with a urinary tract malignancy compared to men

Data support changing the evaluation requirements for microscopic hematuria in this low-risk group of women

Organizations which do not risk-stratify based on gender may continue to recommend more aggressive diagnostic evaluation in low-risk women

USPSTF

No recommendation because current evidence is insufficient to assess the balance of benefits and harms of screening for bladder cancer in asymptomatic adults

AUA & SUFU

AUA and SUFU define microhematuria as follows
- ≥3 red blood cells per high powered field
- Properly collected urinary specimen
Positive dipstick does not define microhematuria but should generate a urinalysis and microscopic examination of urinary sediment
Urine biomarkers (e.g., NMP22) are not recommended for use in routine evaluation
Guidelines use a risk stratification algorithm to determine follow-up (low, intermediate or high risk)
- Low risk: Women age <50 | Men age <40 yrs | Never smoker or <10 pack-years | 3 to 10 RBC/HPF on one UA | No additional risk factors for urothelial cancer1 No prior episodes of microhematuria
- In the case of low risk microhematuria, the guideline states that 6 month follow up should be discussed with the patient in the context of shared decision making

…clinicians should discuss cystoscopy and imaging with renal ultrasound as options for evaluation, but should also review the option to repeat UA, with a plan to escalate to cystoscopy and imaging if the MH is found to persist

Key Points:

Hematuria is associated with urinary tract malignancy and early detection of tumors with malignant potential could have an important effect on the mortality rate of bladder cancer (USPSTF)
Risk factors for bladder cancer include:
- Smoking
- Occupational exposure to carcinogens (e.g., rubber, chemical, and leather industries)
- Male sex
- Older age
- White race
- Infections caused by certain bladder parasites (e.g., Schistosoma haematobium)
- Family or personal history of bladder cancer
Asymptomatic microscopic hematuria is common in women (ranges from 2.4% to 31.1%)
- Less likely to be associated with urinary tract malignancy in women than men
- ACOG and AUGS recommend that going forward, professional organizations produce sex-specific recommendations
Harms associated with false positive screening results include
- Anxiety
- Unnecessary evaluations (e.g., CT radiation exposure) and treatments
- Diagnostic-related from cystoscopy and biopsy
- Overdiagnosis and overtreatment

Learn More – Primary Sources:

ACOG / AUGS Committee Opinion 703: Asymptomatic Microscopic Hematuria in Women

AUGS: Choosing Wisely Campaign

Microhematuria: AUA/SUFU Guideline

USPSTF: Bladder Cancer in Adults: Screening

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ACOG and AUGS Guidance: Asymptomatic Microscopic Hematuria in Women