Microhematuria in Postmenopausal Women: Adherence to Guidelines in a Tertiary Care Setting

Abstract

Purpose In 2012, the American Urological Association released a revision of their asymptomatic microscopic hematuria (AMH) guidelines. Our objectives were to assess adherence to these guidelines and to describe the prevalence of urinary tract malignancy in postmenopausal women at our institution. Materials and Methods This is a cross-sectional analysis of women over age 55 evaluated by Urogynecology or Urology from 8/2012-8/2014 for a diagnosis of AMH. Women who underwent evaluation for ≥3 RBC/HPF on microscopic urinalysis were considered “true AMH.” Those who were evaluated after a dipstick with blood and had <3 RBC/HPF on urinalysis or no urinalysis were considered “positive dipstick.” Demographics, laboratory values, imaging results, and cystoscopy findings were extracted from electronic medical records. Results Our study population included 237 women (mean age 67.1±8.3 years). In our overall population 169/237(71.3%) had true AMH, 48/237(20.3%) had a positive dipstick, and 20/237(8.4%) underwent evaluation in the setting of a urinary tract infection. We detected 3(1.4%) urinary tract malignancies. One kidney cancer was identified in a 56 year-old, current smoker with a urine dipstick of 1+ blood. Two instances of bladder cancer were detected in women aged 58 and 64, one current and one nonsmoker with 6 and 42 RBC/HPF on urinalyses respectively. Conclusions In postmenopausal women evaluated for AMH, the overall prevalence of urinary tract malignancy was low (1.4%). In our population, 28.7% underwent evaluation without meeting guideline criteria for AMH. This demonstrates an opportunity to improve adherence to existing guidelines to provide high-quality care and avoid unnecessary, expensive testing.

Haematuria work-up in general care-A German observational study

“…Two independent questionnaire‐studies investigating the referral pattern of haematuria patients to urological departments confirm this, of which one is even indicating a gender effect that women are referred less than men . On the other hand a portion of 28.7% percent of postmenopausal women with asymptomatic haematuria treated in a north American centre were guided to further diagnostic testing although not meeting the risk criteria adhering to the AUA guideline . The low guideline adherence is carried on in the therapeutic approach of patients with bladder cancer as is remarked by van Rhijn et al …”

“…26,27 On the other hand a portion of 28.7% percent of postmenopausal women with asymptomatic haematuria treated in a north American centre were guided to further diagnostic testing although not meeting the risk criteria adhering to the AUA guideline. 28 The low guideline adherence is carried on in the therapeutic approach of patients with bladder cancer as is remarked by van Rhijn et al 29 Our tract cancer probability of 1.8% in 4020 haematuria patients and both groups were using ultrasound and IVU for evaluation. 21,22 The described approach of the combination of ultrasound and IVU is because of the fact that IVU is easily accessible and integrated in our unit although this is not concordant with the actual AUA guideline recommending CT-scan because of its higher sensitivity for renal and ureteral tumours.…”

Quality of the diagnostic process in patients presenting with symptoms suggestive of bladder or kidney cancer: a systematic review

“…The main bias and applicability concerns related to the suboptimal identification and/or adjustment for confounders in 18 of the studies, 6 of which were studies using questionnaires,14–19 10 were retrospective cohort studies providing descriptive statistics mainly, using record reviews (n=5)20–24 and electronic health records (n=5),25–29 1 was a case–control study30 and 1 an ecological study 31…”

“…Eleven studies reported the percentages of investigations and referrals performed in patients with haematuria,18 21 22 24 25 28 33–36 38 seven of which also specified time-frames during which these evaluations should be completed22 24 28 33–36 (online supplementary appendix 2). Five studies reported that only 5%–25% of these patients received both imaging and cystoscopy (commonly defined as ‘complete evaluation’ by the studies) by 6 months of their first presentation with haematuria25 28 34–36 and case series of 100 patients in a single institution reported this percentage to be 64% in their cohort 22…”

“…One secondary care study reported non guideline-compliant practice in over a third of postmenopausal women with asymptomatic haematuria, with no documentation of full genitourinary examination with vaginal tissue quality and presence of prolapse 21…”