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
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.
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.
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
Pelvic organ prolapse
ACOG & AUGS 2017
No further evaluation required for low risk women that meet the following criteria (risk of malignancy ≤ 0.5%)
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
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
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:
Occupational exposure to carcinogens (e.g., rubber, chemical, and leather industries)
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
Unnecessary evaluations (e.g., CT radiation exposure) and treatments
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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