Primary Care

CMECNE

Microhematuria: The Latest AUA/SUFU Guideline Recommendations

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. State the definition of microhematuria according to the AUA/SUFU guideline
2. Discuss the risk-stratification approach to the management of microhematuria

Estimated time to complete activity: 0.25 hours

Faculty:

Ashley Comfort, MD, FACOG is the Director of Medical Content, 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: Ashley Comfort, MD, has a financial interest in Pfizer and has no other conflicts of interest to disclose.

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 3/31/2021 through 3/31/2023, 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 test and evaluation. Upon registering and successfully completing the test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

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 0.25 contact hours.

Read Disclaimer & Fine Print

SUMMARY:

Hematuria accounts for approximately 20% of all Urology referrals. It is typically characterized as either gross (visible blood in urine) or microhematuria (RBCs on UA). Hematuria can be linked to a variety of etiologies, including infection, calculi, BPH, and—most importantly—malignancy. Studies have shown vastly different rates of genitourinary (GU) malignancy in patients with hematuria (<1% to 10%). While patients with gross hematuria generally undergo cystoscopy to rule out cancer, the evaluation and management of microhematuria (MH) is more nuanced. The 2012 American Urological Association (AUA) guideline recommended cystoscopy and CT urogram for all patients >35 with MH. An updated 2020 AUA/ Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) guideline introduces a system of stratifying patients based on risk for GU malignancy to help guide diagnostic evaluation.

Diagnosis

Definition of MH
- ≥3 RBCs/HPF on UA
- Not diagnosed by urine dipstick

Work-up of MH

H&P to identify possible sources
- e.g. UTI, medical renal disease, gynecologic, malignancy
- Urine cytology not recommended as part of initial evaluation
Workup does not vary for patients on antiplatelets or anticoagulation
If gynecologic or non-malignant GU source identified, treat accordingly and repeat UA upon resolution
Refer to nephrologist if renal disease identified (e.g. cellular casts, proteinuria, elevated creatinine, or hypertension)
Categorize patient based on risk for GU malignancy to guide further workup

KEY POINTS:

Risk Stratification

Low-risk: Must Meet All of the Following Criteria

Women < 50 | Men < 40
Smoking history: Non-smoker or <10 pack-years
UA: 3 to 10 RBCs/HPF and no prior MH
No additional risk factors for GU cancer, which include the following
- Irritation with voiding | Cyclophosphamide/ifosfamide chemotherapy | Family history of GU cancer or Lynch Syndrome, industrial exposure to benzenes/aromatic amines(e.g. printers, painters, concrete workers, textile workers, plastics and metal workers., chronic indwelling foreign body in GU tract)

Intermediate-risk: Must meet ≥1 of the following criteria

Women 50 to 59 | Men 40 to 59
Smoking history: 10 to 30 pack-years
UA: 11 to 25 RBCs/HPF (or previously low-risk with no diagnostic workup and 3 to 25 RBCs/HPF)
≥1 additional risk factor for GU cancer (see above)

High-Risk: Must Meet ≥1 of the Following Criteria

Women and men ≥ 60
Smoking history: > 30 pack-years
UA: > 25 RBCs/HPF
History of gross hematuria

Management

Low-risk: Choice of option based on shared decision-making
- Repeat UA within 6 months or
- Cystoscopy and renal ultrasound
Intermediate-risk
- Cystoscopy and renal ultrasound
High-risk
- Cystoscopy and CT urogram

Note: For all risk categories: If negative workup, “consider” repeat UA within 12 months

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Microhematuria: AUA/SUFU Guideline

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