Clinical guidelines: Clearing murky water -- a guideline-based approach to haematuria

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Clearing murky water a guideline-based approach to haematuria

gold-standard radiological test for haematuria. Conversely the Canadian5 and Dutch7 groups promotethe use of renal ultrasonography, justifying this choice by referring to data on secondary malignancies that might arise as a result of radiation

exposure from

radiographic

imaging techniques.

Nielsen and Qaseem4 summarize the discrepancies between recommendations of the existing guidelines, and discuss the risks and financial costs associated with use of haematuria workup before proceeding with a review of current practice, and risk stratification for genitourinary malignancies in patients with microhaematuria. Using a synthesis of existing evidence, expert opinion and risk stratification, these authors make a series of recommendations. Citing the more dire clini cal implications of gross haematuria compared with microhaematuria, and the fact that many patients with microhaematuria admit to an episode of gross haematuria when specifically asked2, the authors recommend the inclusion of gross haematuria questioning in the review of systems. These authors discourage the use of routine screening urinalysis owing to a lack of evidence supporting its effectiveness in clinical practice. In asymptomatic adults, a confirmatory microscopic urinalysis should demonstrate three or more erythrocytes per high-powered field to justify a formal haematuria workup. Urology referral

manuscript includes an evalu ation of guidelines provided by the AUA3, theCanadian Urological Association5, the British Association of Urological Surgeons6 and the Dutch Guidelines7 on the evaluation of asymptomatic microscopic haematuria as well as the AUA best practice policy (2001). Guidelines published by all four groups discourage the use of urinalysis as a routine screening tool. The Canadian5, Dutch7 and American3 guidelines all suggest that urin alysis alone does not provide sufficient evidence to proceed with a full haematuria workup. These guidelines recommend proceeding to a microscopic evaluation, with a minimum requirement of three erythrocytes per high-powered field to justify any further workup. The Dutch7

and Canadian5 groups also advocate for a minimum of two out of three erythrocyte- positive microscopic urin alyses prior to proceeding to a full workup; whereas the 2012 AUA guidelines3 shifted the American stance to view a single positive microscopic evaluation as sufficient, citing the often intermittent nature of haematuria....