The presence of blood in the urine, or hematuria, is a common finding in clinical practice and can sometimes be a sign of occult cancer.
Symptomatic gross hematuria with associated flank pain or renal colic is the classic presentation of urinary stone disease, whereas painless gross hematuria has a stronger association with cancer. Any episode of gross hematuria in an adult warrants consideration of urgent urologic evaluation, given the relatively high pretest probability of cancer or other clinically significant underlying conditions (consistently >10% and >25% in some referral series ). Asymptomatic microscopic hematuria (AMH) is more commonly encountered, with prevalence estimated at 0.9% to 18.0% in the adult population in the US. Patients referred for AMH have a relatively lower (0.5% to 5.0%) but nontrivial probability of underlying occult cancer that is estimated to range from 7% to greater than 20% in higher-risk subgroups in some series.
In 2016, American College of Physicians came out with the Clinical Guidelines ( Advice for High-Value Care ) on Hematuria as a Marker of Occult Urinary Tract Cancer.
The major recommendations of the guidelines are as follows:-
- Clinicians should include gross hematuria in their routine review of systems and specifically ask all patients with microscopic hematuria about any history of gross hematuria.
- Clinicians should not use screening urinalysis for cancer detection in asymptomatic adults.
- Clinicians should confirm heme-positive results of dipstick testing with microscopic urinalysis that demonstrates 3 or more erythrocytes per high-powered field before initiating further evaluation in all asymptomatic adults.
- Clinicians should refer for further urologic evaluation in all adults with gross hematuria, even if self-limited.
- Clinicians should consider urology referral for cystoscopy and imaging in adults with microscopically confirmed hematuria in the absence of some demonstrable benign cause.
- Clinicians should pursue evaluation of hematuria even if the patient is receiving antiplatelet or anticoagulant therapy.
- Clinicians should not obtain urinary cytology or other urine-based molecular markers for bladder cancer detection in the initial evaluation of hematuria.
You can read the full guidelines by clicking on the following link:-
Hematuria as a Marker of Occult Urinary Tract Cancer: Advice for High-Value Care From the American College of Physicians