Clinical Guideline on Hematuria Released by ACP

Diana Phillips

January 28, 2016

A new clinical guideline on hematuria from the American College of Physicians (ACP) urges clinicians to routinely ask patients whether they have a history of visible blood in their urine, particularly those patients in whom microscopic evidence of hematuria has been identified.

Clinicians should refer all adult patients with gross hematuria, even if it is self-limited, for further urologic evaluation, according to the guidance document, which was published online January 26 in the Annals of Internal Medicine.

"[E]merging evidence suggests that a history of self-limited gross hematuria may be a common, important, and significantly underreported symptom," Matthew Nielsen, MD, from the University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, and Amir Qaseem, MD, PhD, director of the Department of Clinical Policy at the ACP in Philadelphia, Pennsylvania, write.

The authors, as part of the High Value Care Task Force of the ACP, conducted a narrative review of the literature, looking at the evaluation of hematuria as a marker of occult urinary tract cancer and other relevant studies to "help clinicians make high-value decisions about referral of patients for urologic assessment," they write.

The authors' review of current clinical practice identified unexplained variation in referral practices for patients with hematuria, despite the strong association between hematuria and cancer, as well as other potentially serious underlying conditions.

Although little controversy surrounds the indication for urologic evaluation for patients with visible blood in the urine (gross hematuria), "the evaluation of patients with the more common finding of [asymptomatic microscopic hematuria (AMH)] is complicated by a lack of clarity about indications for referral and optimal components of the evaluation," the authors write.

"The differing algorithms of existing recommendations for the evaluation of AMH reflect both current uncertainty in this area of practice and differences of opinion about the implicit tradeoffs among the harms, costs, and benefits of a given approach," they state.

The document recommends against screening healthy, asymptomatic patients with urinalysis for the purpose of cancer detection, which is consistent with recommendations of major health organizations.

In addition, the ACP recommends that:

  • "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 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."

"Another important educational message for clinicians is that routine cytologic evaluation of urine is no longer recommended in the initial AMH evaluation," the authors write, noting also that urine-based molecular markers for bladder cancer detection are also not recommended at this initial stage.

The authors also point to the need for further research "to strengthen the evidence base supporting a high-value approach to the evaluation of the common finding of AMH."

In the meantime, they write, "[i]ncreased awareness of the substantially stronger association of gross hematuria with cancer and other potentially serious underlying conditions is a key educational message for patients and practitioners."

Dr Nielsen reported receiving personal fees from the ACP during the conduct of the study and from Grand Rounds and Urology Care Foundation/Astellas outside of the submitted work, and grants from the American Cancer Society and National Institutes of Health outside the submitted work. The other authors have disclosed no relevant financial relationships.

Ann Intern Med. Published online January 26, 2016. Full text

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