Hematuria remains one of the most common urologic diagnoses, estimated to account for over 20% of urology evaluations. While most experts agree that patients with gross hematuria should be evaluated with cystoscopy, upper tract imaging and urinary cytology, significant variability exists across current guidelines and consensus statements regarding microhematuria, particularly the definition of microhematuria, criteria for evaluation, as well as the appropriate components of the evaluation, including the optimal imaging modality. The purpose of this guideline is to provide a clinical framework for the diagnosis, evaluation, and follow-up of microhematuria.

The need exists for clear guideline recommendations for evaluation of hematuria that limit the unnecessary risks and costs associated with the over-evaluation of patients who are at low risk for malignancy, while at the same time addressing the delays in diagnosis of important urologic conditions caused by widespread under-evaluation and variations in care. As the intensity of microhematuria investigation involves tradeoffs at the individual level (risk of malignancy versus harms of evaluation), it is necessary for the clinician and patient to engage in shared decision-making, particularly in situations where the ratio of benefits to harms is uncertain, equivalent or “preference sensitive.” Topics covered in this Guideline include the following:

• Diagnosis and definition of microhematuria
• Initial evaluation
• Risk stratification and risk-based evaluation
• Urinary markers
• Patient follow-up