Gross and Microscopic Hematuria

Hematuria, defined as the abnormal presence of blood in the urine, ranks among the most commonly diagnosed urological disorders, accounting for over 20% of all urological evaluations. While hematuria can be classified in multiple ways—eg, intermittent or constant, glomerular or nonglomerular, and symptomatic or asymptomatic—the most clinically useful distinction separates cases into gross (visible) and microscopic (invisible) hematuria. Microhematuria is defined as the detection of 3 or more urinary red blood cells (RBCs) per high-power field (HPF) on microscopic urinalysis without an apparent cause, while the urine’s visual appearance remains normal. Urinary dipstick findings alone do not provide a definitive diagnosis of microscopic hematuria and require confirmation through one or more microscopic urinalyses. Microscopic examination of urinary sediment must always accompany dipstick-positive findings to verify microhematuria. The absence of microscopic RBCs in strongly dipstick-positive samples suggests alternative causes, eg, myoglobinuria, hemoglobinuria from lysed erythrocytes, or other forms of pseudohematuria. Blood from recent urological procedures, urinary tract infections (UTIs), or contamination from rectal or vaginal bleeding must also be excluded. This approach addresses the relatively high incidence of false positives and negatives associated with dipstick testing alone. Microscopic hematuria can be further categorized into symptomatic microhematuria, asymptomatic microhematuria with proteinuria—indicative of potential glomerular disease—and asymptomatic microhematuria without proteinuria, which raises concern for possible urothelial malignancy. Microscopic urinalysis can also detect urinary infections and abnormal urinary sediment not identified by dipstick, eg, crystals, casts, and dysmorphic RBCs, thereby supporting the diagnosis of the underlying pathology. Enhancing primary care education on definitions of hematuria and initial diagnostic steps can reduce unnecessary testing and referrals while improving the management of patients with confirmed microhematuria. Renal or urothelial malignancy represents the most severe potential cause of hematuria. Evidence indicates that many patients with true microhematuria are not evaluated appropriately or referred promptly to urology, potentially delaying cancer diagnosis and worsening outcomes. One study found that only 41% of primary care patients with dipstick-diagnosed microscopic hematuria received confirmatory microscopic urinalysis, and of those, only 24% had 3 or more RBC/HPF, confirming microhematuria. Another study found that 84% of patients with positive microscopic urinalysis were not further evaluated or tested, highlighting dangerous lapses in guideline implementation. Addressing these gaps is critical to enable early diagnosis of life-threatening conditions and optimize patient outcomes. Multiple classifications stratify patients into low-, intermediate-, and high-risk categories. The most widely used and validated framework follows the updated 2025 American Urological Association Guideline on Microhematuria Risk Stratification. Some sources advocate for a more stringent requirement of at least 2 or 3 confirmed microscopic findings before confirming hematuria. In cases where only a single microscopic finding is present, periodic follow-up urinalyses for at least 1 year are recommended if no further workup is performed after the initial result.