Examqo › Examqo library › Urology › Urological oncology · IMLE
Haematuria evaluation: microscopic and gross
Gross haematuria always requires a full evaluation — cystoscopy and CT urography — whereas microscopic haematuria (3 or more red cells per high-power field on one microscopic examination) is evaluated according to risk level.
Why it matters in the exam
This is one of the commonest questions in urology and internal medicine: a patient with blood in the urine, sometimes a smoker or on anticoagulants, and the question is the correct evaluation. Under AUA/SUFU the definition rests on microscopy and not on a dipstick alone; a positive dipstick requires microscopy. Before the evaluation benign causes are excluded — menstruation, vigorous exercise, urinary infection — and if there is an infection it is treated and the test is repeated. Anticoagulants do not "explain" haematuria and do not exempt the patient from evaluation.
Risk groups in microhaematuria: low risk — a woman under 50 or a man under 40, fewer than 10 pack-years, 3 to 10 red cells; here the test can be repeated in 6 months or cystoscopy and ultrasound performed by shared decision. Intermediate risk — a woman aged 50 to 59 or a man aged 40 to 59, 10 to 30 pack-years, 11 to 25 red cells; here cystoscopy and renal ultrasound. High risk — age 60 or over, more than 30 pack-years, more than 25 red cells or a history of gross haematuria; here cystoscopy and CT urography.
Signs of a glomerular source — dysmorphic red cells, red cell casts, proteinuria or a rising creatinine — point to a parallel nephrology referral. Urine cytology is not a routine part of microhaematuria evaluation, but it has a place in gross haematuria with irritative symptoms or a suspicion of CIS. In gross haematuria with clots and retention a three-way catheter is inserted and the bladder irrigated. When contrast cannot be given, MR urography or retrograde pyelography with ultrasound can be used.
Key points
- Definition: 3 or more red cells per high-power field.
- Gross haematuria — cystoscopy and CT urography.
- Intermediate risk — cystoscopy and ultrasound.
- Anticoagulants do not exempt from evaluation.
- Glomerular signs — nephrologist.
Summary table
| Risk group | Criteria | Evaluation |
|---|---|---|
| Low | Woman under 50, man under 40; fewer than 10 pack-years; 3 to 10 red cells | Repeat in 6 months or cystoscopy and ultrasound |
| Intermediate | Woman 50 to 59, man 40 to 59; 10 to 30 pack-years; 11 to 25 red cells | Cystoscopy and renal ultrasound |
| High | Age 60 or over; more than 30 pack-years; more than 25 red cells | Cystoscopy and CT urography |
| Gross haematuria | Any age | Cystoscopy and CT urography |
| Glomerular source | Dysmorphic red cells, casts, proteinuria | Nephrology referral |
A free exam question
מטופל עם המטוריה מיקרוסקופית אסימפטומטית נבדק במרפאה. מה מהבאים נכון בהתייחס למצב זה? (the question as examined, in Hebrew)
- א. HPF כדוריות דם בשדה 10 המטוריה מיקרוסקופית מוגדרת מעל
- ב. מהאוכלוסיה באופן טבעי 26% -קיימת בכ
- ג. ממאירות מאובחנת בכ- 3.5% ממטופלים עם מיקרו-המטוריה
- ד. ניתן לאבחן מיקרו-המטוריה בסטיק שתן
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
The full version is open to subscribers of: Urology, Medical licensing exam (IMLE), Internal medicine, Family medicine.
Subscriber? Read the full topic Plans and prices 25 free questions
Sources
- AUA/SUFU Guideline: Microhematuria, 2020 — Evaluation and risk stratification
- EAU Guidelines on Non-muscle-invasive Bladder Cancer, 2025 edition — Diagnostic evaluation
- Campbell-Walsh-Wein Urology, 12th edition (2020) — Evaluation of the Urologic Patient: History, Physical Examination, and Urinalysis
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.