Intended for healthcare professionals

Clinical Review

Assessment and management of non-visible haematuria in primary care

BMJ 2009; 338 doi: (Published 16 January 2009) Cite this as: BMJ 2009;338:a3021
  1. John D Kelly, senior lecturer1,
  2. Derek P Fawcett, consultant urologist2,
  3. Lawrence C Goldberg, consultant nephrologist3
  1. 1Department of Oncology, Cambridge University, Addenbrooke’s Hospital, Cambridge CB2 0QQ
  2. 2Harold Hopkins Department of Urology, Royal Berkshire Hospital, Reading RG1 5AN
  3. 3Sussex Kidney Unit, Brighton and Sussex University Hospitals NHS Trust, Royal Sussex County Hospital, Brighton BN2 5BE
  1. Correspondence to: J D Kelly jk334{at}
  • Accepted 26 November 2008

Summary points

  • The terms visible haematuria should replace macroscopic or gross haematuria, and non-visible haematuria (both symptomatic and asymptomatic) should replace microscopic haematuria or dipstick positive haematuria

  • Urine testing for haematuria should be performed for clinical reasons only—current evidence does not support opportunistic testing

  • The test of choice for diagnosing haematuria is urine dipstick analysis—scores of ≥1+ are positive

  • Transient or spurious causes of haematuria need to be excluded

  • All patients aged ≥40 with haematuria should be investigated for urological disease

  • All patients with no identified urological cause should be monitored long term

Many clinicians are not sure what constitutes clinically relevant haematuria; they are also unsure about when patients with haematuria should be referred for specialist assessment and whether they should be referred to a urologist, nephrologist, or both.

In 2006 the National Institute for Health Research, Health Technology Assessment (NIHR HTA) commissioned a systematic review of the evidence for the investigation of microscopic haematuria, with a view to developing an algorithm for assessing patients in primary care.1 They concluded that, “Given the paucity of evidence . . . it is not possible to derive an algorithm of the diagnostic pathway for haematuria that would be solely supported by existing evidence.” None the less, the investigation of microscopic haematuria is important because serious underlying conditions are present in a proportion of patients.

Sources and selection criteria

We drew on evidence published in the systematic reviews of the National Institute for Health and Clinical Excellence, Health Technology Assessment (microscopic haematuria),1 and guidelines for the early diagnosis and management of chronic kidney disease.1 2 We searched electronic databases, including Medline and the Cochrane database, to identify recent publications and studies that were deemed relevant but outside the inclusion criteria of the systematic review. We included the evidence presented in published guidelines for the investigation …

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