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Gross and microscopic hematuria

AUA/SUFU 2025 confirmation, risk stratification, cystoscopy and upper-tract evaluation for adult hematuria.

JurisdictionUnited States
Source check2026-08-20
Clinical reviewiatroX editorial team 路 Clinical editorial review 路 reviewed 2026-08-20 路 due 2027-08-20
AudienceUnited States healthcare professionals
This is an iatroX educational summary of named United States sources, not an official guideline. It does not replace the complete source documents, local policy, specialist advice or clinical judgement. Use the named authority, current FDA labeling, applicable state law, payer rules and local protocol where relevant.

Scope of this summary

Adults with visible blood in urine or at least three red blood cells per high-power field on microscopic urinalysis. Dipstick alone does not define microhematuria. Menstrual or genital bleeding, glomerular disease, trauma and pediatric hematuria require parallel or separate evaluation.
sources for this section:AUA/SUFU 2025

The Bottom Line

  • Confirm a positive dipstick with microscopic urinalysis and establish whether blood is gross, persistent or associated with infection, proteinuria, kidney dysfunction, stones or urologic cancer risk.
  • Evaluate patients taking anticoagulant or antiplatelet therapy under the same hematuria framework; medication can reveal bleeding but does not remove the possibility of malignancy.
  • After treating a urinary tract infection or another plausible nonmalignant cause, repeat urinalysis to document resolution rather than assuming the episode is closed.
  • Apply the 2025 AUA/SUFU low/negligible-, intermediate- or high-risk microhematuria framework using age, sex, smoking, degree and persistence of blood, history of gross hematuria and other urothelial risk factors.
  • Use risk-matched cystoscopy and upper-tract assessment: repeat urinalysis can be appropriate at lowest risk, while intermediate and high risk require progressively more complete bladder and upper-tract evaluation.
sources for this section:AUA/SUFU 2025

Practical clinical workflow

1
Confirm source and timing, quantify tobacco and occupational exposure, record stones, infection, pelvic radiation, cyclophosphamide, family cancer syndromes and urinary symptoms, and examine for genital or renal clues.
2
Obtain microscopic urinalysis, culture when infection is possible, kidney function and protein assessment; prominent proteinuria, dysmorphic cells, casts or impaired kidney function supports nephrology involvement.
3
Treat a proven transient cause and repeat urinalysis after an appropriate interval; persistent blood is reclassified by the AUA/SUFU risk system rather than repeatedly treated empirically.
4
Refer gross hematuria or risk-qualified microscopic hematuria to urology with complete exposure and laboratory information for cystoscopy and appropriate renal ultrasound or axial upper-tract imaging.
5
After a negative evaluation, use shared follow-up based on persistence, risk and new symptoms; a later episode of gross blood, increased microscopic blood or new urologic symptom warrants renewed assessment.
sources for this section:AUA/SUFU 2025

Safety boundaries and escalation

  • Clot retention, inability to void, hemodynamic compromise, severe anemia, fever with obstruction or acute kidney injury requires urgent urologic and emergency management.
  • Do not dismiss gross hematuria as infection, BPH, menstruation or anticoagulation without confirming source and completing the indicated pathway.
  • Contrast-based upper-tract imaging requires kidney, allergy and pregnancy assessment, with an alternative chosen when contraindicated.
  • Concurrent nephrology findings do not eliminate urologic cancer risk; both pathways may be necessary.
sources for this section:AUA/SUFU 2025

Localization

Exact risk-table implementation must be checked against the current AUA document.
sources for this section:AUA/SUFU 2025

Source documents

Use the linked source documents for complete recommendations, evidence grading, exclusions and implementation detail.

  1. American Urological Association and Society of Urodynamics, Female Pelvic Medicine & Urogenital ReconstructionMicrohematuria: AUA/SUFU Guidelinepublished 2020; amended 2025 路 published 2020-10-01 路 updated 2025-02-01 路 accessed 2026-08-20
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