Emily Bochner, MD, and Yair Lotan, MD
Department of Urology, University of Texas Southwestern, Dallas
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KEYWORDS:
Hematuria; urologic neoplasms; urinary bladder neoplasms
Abstract
Recent updates to the American Urological Association microhematuria guidelines further stratify patients’ risk of malignancy based on recent, validated data from the 2020 risk stratification system and provide better elucidation of malignancy risk based on risk category. Important changes include reclassifying patients who are “low risk” as “low or negligible risk,” supporting the use of biomarkers in select intermediate-risk patients, and adjusting age cutoffs for risk groups in women. In addition, important guidance on follow-up visits after negative hematuria evaluation is expanded upon and provides valuable insights for the practicing urologist.
In 2020, the American Urological Association (AUA) provided new guidelines for the workup and evaluation of microhematuria.1 These updated statements provided risk stratification for patients presenting with microhematuria into low-risk, intermediate-risk, and high-risk groups based on sex, age, smoking history, and number of red blood cells per high-powered field on urinalysis. Patient-centered recommendations for further evaluation and intervention were provided based on these risk groups and on the potential for diagnosing an underlying malignancy. Since the release of the 2020 microhematuria guidelines, high-quality studies validating these risk categories have come out that have subsequently better elucidated the risk of malignancy based on risk groups.2-4 The findings of these studies have prompted a recent update to the microhematuria guidelines.5
The 2025 AUA microhematuria guidelines highlight the most up-to-date and accurate rates of malignancy diagnosis based on AUA risk category. The risk of identifying an underlying genitourinary malignancy is approximately 0% to 0.4% in the low-risk or negligible-risk group, 0.2% to 3.1% in the intermediate-risk group, and 1.3% to 6.3% in the high-risk group (Table 1).2-4 Further updates have been made to the microhematuria guidelines from the AUA with the Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction that reflect the findings of these important studies, and these changes are applicable to all practicing urologists. Two notable changes related to the risk stratification system used in the microhematuria guidelines are (1) changing the lowest risk classification group from “low risk” to “low or negligible risk” and (2) adjusting the age-related risk category classifications for women (Table 2). These changes were based on the previously mentioned studies, which sought to validate the 2020 risk stratification and better assess the risk of malignancy. One study by Sanci et al4 evaluated more than 1000 men and women with microhematuria and found no cancer diagnoses in the low-risk group. Woldu et al2 similarly evaluated almost 16 000 patients with microhematuria (from recent clinical biomarker trials and prospective registries) and found that the risk of bladder cancer diagnosis in the low-risk group was 0.4%. Saxon et al3 evaluated approximately 1700 women with microhematuria and found a 0% malignancy diagnosis rate in low-risk patients. As a consequence of this very low risk of cancer, the guidelines now state that for patients with low or negligible risk, clinicians should obtain repeat urinalysis within 6 months of the index urinalysis rather than perform immediate cystoscopy or imaging. This change is a substantial departure from the shared decision-making recommendation in prior guidelines.1
The Saxon study3 also found that the risk of malignancy diagnosis in women younger than 60 years of age was very low in the absence of other risk factors. This finding prompted the updated guidelines to change the age ranges within the risk groups so that women younger than 60 years of age are considered to have a low or negligible risk and women 60 years of age and older are considered to have intermediate risk. Based on the overall lower malignancy risk in women, the 2025 updates suggest that women should not be classified as having a high risk of cancer based on age alone.5 Women can still be categorized as having intermediate or high risk based on other risk factors, such as the number of red blood cells in urine or smoking intensity.
The recent updates have also provided guidance on the management of patients with a negative hematuria workup. For most patients who have previously undergone an appropriately risk-stratified hematuria workup with negative findings, the guidelines suggest that they can be safely discharged from urologic care through a shared decision-making approach.5 This suggestion is based on evidence that repeating a workup in patients with a previously negative microhematuria evaluation has minimal diagnostic value, particularly when they have no new symptoms or episodes of gross hematuria, with studies showing no difference in malignancy risk between patients with and without previous microhematuria.6,7 Certainly there may be patients with additional risk factors (ie, heavy smoking, urinalyses with a greater number of red blood cells per high-powered field) who are hesitant to forgo urologic care or patients who generally do not feel comfortable being discharged from the urology clinic. The guidelines suggest that it is reasonable to repeat a urinalysis in these patients given the procedure’s simple, noninvasive nature and quantitative data on the degree of microhematuria.5 If the repeat urinalysis is negative, however, no further evaluation is recommended. Even in patients with persistent or recurrent microhematuria after a negative workup, the rate of malignant diagnoses is low; malignant diagnoses are typically found years down the line.8 The decision to pursue continued evaluation for microhematuria after a negative workup should therefore be determined after thorough counseling of patients regarding the relatively low benefit of additional clinic visits, laboratory analysis, and imaging in the setting of a low rate of malignancy detection. If patients develop new symptoms, including gross hematuria, after a negative microhematuria workup, further evaluation is indicated.5 The guidelines ultimately emphasize the importance of shared decision-making and careful clinical judgment when determining whether to repeat an evaluation after a negative microhematuria evaluation.
Finally, the guidelines have provided an updated statement on the role of urine biomarkers in the microhematuria workup. The general goal of urine biomarkers is to help clinicians appropriately identify patients with a high likelihood of harboring underlying cancer (ideally leading to high-yield evaluations) while also accurately identifying patients with a low likelihood of cancer, thereby avoiding unnecessary intervention. The current guidelines do not recommend using urine cytology or urine biomarkers to decide whether to perform a cystoscopy in low- to negligible-risk or high-risk patients or as an adjunct test in the setting of a normal cystoscopy.5 This lack of recommendation is based on the overall low likelihood of identifying cancer in the low- or negligible-risk patient cohort and the increased risk of unnecessary evaluations related to false-positive results given the current limitations of available urine biomarkers.9
In addition, in high-risk patients, no urine biomarker has been proven reliable enough to safely avoid cystoscopy in those patients with a higher likelihood of underlying cancer. In the intermediate-risk group, however, a new conditional recommendation is provided regarding the use of urine biomarkers in patients interested in avoiding cystoscopy. Guideline statement 13 suggests that in appropriately counseled patients with intermediate risk who are comfortable forgoing cystoscopy and direct visual evaluation of the bladder, clinicians can offer urine cytology or a urine biomarker to help guide the decision to pursue cystoscopy.5 This recommendation is supported by a recent systematic review that found that most urine biomarkers have a very low negative likelihood ratio, meaning that there is a very low likelihood of underlying cancer in the setting of a negative test result, as well as very high negative predictive value, meaning that a negative test is highly likely to represent the absence of malignancy.9
In intermediate-risk patients, the guidelines state that the overall high negative predictive value of most urine biomarkers would result in a reassuringly low chance of missing underlying cancer with a negative marker.5 After appropriate counseling and patient-centered discussion, clinicians may offer urine biomarker analysis to assess the need for cystoscopy and now have data supporting the decision to forgo cystoscopy with a negative result based on the overall low risk of missing cancer. The guidelines identify several urine biomarkers with sufficient evidence to support their use based on studies that have evaluated sufficient numbers of patients with microhematuria. The guidelines note that a kidney ultrasound should still be performed in the intermediate-risk group, regardless of whether cystoscopy or urine biomarker evaluation is pursued. Guideline statement 14 furthermore suggests that for those patients who forgo cystoscopy based on reassuring urine biomarker results, a repeat urinalysis should be obtained and a cystoscopy should be pursued if microhematuria persists.5 The guidelines highlight the need for future studies investigating the role of biomarkers in further evaluating microhematuria risk assessment.
The 2025 updates to the microhematuria guidelines improve upon the 2020 risk stratification by using recent data to provide more accurate risk stratification for patients presenting with microhematuria, with up-to-date rates of malignancy based on risk groups. The updates also include a novel support statement regarding the use of urine biomarkers in intermediate-risk patients interested in forgoing cystoscopy. Clarity on a once-gray area of how to assess a patient with a negative hematuria workup has been provided with data-driven recommendations. As mentioned in the guidelines, ongoing studies are needed to determine the developing role of biomarkers in this space.
Barocas DA, Boorjian SA, Alvarez RD, et al. Microhematuria: AUA/SUFU Guideline. J Urol. 2020;204(4):778-786. doi:10.1097/JU.0000000000001297
Woldu SL, Ng CK, Loo RK, et al. Evaluation of the new American Urological Association guidelines risk classification for hematuria. J Urol. 2021;205(5):1387-1393. doi:10.1097/JU.0000000000001550
Saxon GM, Patil D, Hammett J. Microhematuria in women: prevalence of malignancy and risk score evaluation. Urology. 2022;160:34-39. doi:10.1016/j.urology.2021.11.003
Sancı A, Oktar A, Gokce MI, et al. Comparison of microscopic hematuria guidelines as applied in 1018 patients with microscopic hematuria. Urology. 2021;154:28-32. doi:10.1016/j.urology.2021.04.031
Barocas DA, Lotan Y, Matulewicz RS, et al. Updates to microhematuria: AUA/SUFU guideline (2025). J Urol. 2025;213(5):547-557. doi:10.1097/JU.0000000000004490
Lisanti CJ, Graeber A, Syed H, et al. What is the relative risk of urologic malignancy in microscopic hematuria patients after negative evaluation? A long-term population-based retrospective analysis of 8465 patients. Abdom Radiol (NY). 2023;48(3):1011-1019. doi:10.1007/s00261-022-03793-x
Madeb R, Golijanin D, Knopf J, et al. Long-term outcome of patients with a negative work-up for asymptomatic microhematuria. Urology. 2010;75(1):20-25. doi:10.1016/j.urology.2009.06.107
Pak JS, Wang EY, Lee K, Pina LA, McKiernan JM, Anderson CB. Diagnostic yield of repeat evaluation for asymptomatic microscopic hematuria after negative initial workup. Urol Oncol. 2021;39(5):300.e1-300.e6. doi:10.1016/j.urolonc.2020.11.032
Woldu SL, Souter L, Boorjian SA, Barocas DA, Lotan Y. Urinary-based tumor markers enhance microhematuria risk stratification according to baseline bladder cancer prevalence. Urol Oncol. 2021;39(11):787.e1-787.e7. doi:10.1016/j.urolonc.2021.03.022
Published: June 23, 2025.
Conflict of Interest Disclosures: Emily Bochner has no financial relationships to disclose. Yair Lotan is a consultant for Ambu; AstraZeneca; Aura Biosciences, Inc; CAPS Medical; CG Oncology; Convergent Genomics; FerGene; Immunity Bio; Janssen; Merck; Nonagen Bioscience; NRx Pharmaceuticals; Nucleix; Pacific Edge; Pfizer; Phinomics Inc; Photocure; Promis Diagnostics; Relmada Therapeutics, Inc; Seattle Genetics; Stimit; Trigone Pharma; Uroessentials; UroGen; UroViu Corporation; Valar Labs; Vesica Health; Vessi Medical; and Virtuoso Surgical.
Funding/Support: None.
Author Contributions: Both authors had the final responsibility for the decision to submit for publication.
Data Availability Statement: All data sources used in this article are publicly available.
Citation: Bochner E, Lotan Y. 2025 American Urological Association microhematuria guidelines: what urologists need to know. Rev Urol. 2025;24(2):e25-e28.
Corresponding author: Yair Lotan, MD, Department of Urology, The University of Texas Southwestern Medical Center, 5300 Harry Hines Blvd, Dallas, TX 75390 (yair.lotan@utsouthwestern.edu)