# Microscopic Haematuria (Evaluation & Referral) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: AUA/SUFU Guideline on Microhematuria 2020 · Enalapril Maleate 10mg tablets SmPC section 4.2 Posology and method of administration (eMC product 561) · Gross and Microscopic Hematuria - disease-level clinical article (microscopic-haematuria-referral-full.txt) - Verified date: 2026-08 ## Verified against - Enalapril Maleate 10mg tablets SmPC section 4.2 Posology and method of administration (eMC product 561) - Gross and Microscopic Hematuria - disease-level clinical article (microscopic-haematuria-referral-clinical.txt) ## Treatment metadata - Enalapril — 5 mg — oral.solid - Referral & safety-netting (no drug therapy) ## Complete treatment card ```text MICROSCOPIC HAEMATURIA (EVALUATION & REFERRAL) Sources: AUA/SUFU Guideline on Microhematuria 2020 · Enalapril Maleate 10mg tablets SmPC section 4.2 Posology and method of administration (eMC product 561) · Gross and Microscopic Hematuria - disease-level clinical article (microscopic-haematuria-referral-full.txt) Review status: REVIEWED against Enalapril Maleate 10mg tablets SmPC section 4.2 Posology and method of administration (eMC product 561), Gross and Microscopic Hematuria - disease-level clinical article (microscopic-haematuria-referral- clinical.txt) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (12) - A family history of Lynch syndrome or a hereditary renal-cancer syndrome raises cancer risk - Occupational exposure to benzene, aromatic amines, or Agent Orange raises urothelial cancer risk - A history of pelvic radiotherapy is a high-risk factor for urothelial cancer - Prior chemotherapy with cyclophosphamide or ifosfamide raises the risk of urothelial cancer - Persistent, unexplained irritative urinary symptoms are a high-risk factor for urothelial cancer - A past episode of unexplained visible blood in the urine is itself a high-risk factor [blood in the urine] - An indwelling catheter or suprapubic tube raises cancer risk - Being on a blood thinner does not exclude an underlying cause and needs the same work-up - A recent throat or skin infection is worth asking about - Voiding symptoms to ask about include dysuria, frequency, hesitancy, incomplete emptying, an intermittent stream, urgency, or a weak stream [burning on passing urine · poor urinary stream] - Passing a urinary stone can itself be a reported symptom - Red flag: many patients with true microscopic bleeding are never properly worked up or sent to urology in time, and a cancer diagnosis is delayed by it [bleeding] SIGNS - what you find (6) - Costovertebral angle tenderness, along with fever or leg swelling, may accompany a renal source of bleeding [abdominal pain · bleeding · fever · leg swelling · loin pain] - Hypertension, joint swelling, or enlarged lymph nodes may be found on examination [hypertension · joint swelling · lymphadenopathy] - A palpable, enlarged, cystic kidney can be felt on abdominal exam - Meatal blood or a urethral caruncle may be visible on genital exam - Periorbital puffiness, together with pallor, jaundice, mouth ulcers, or rash, points toward a systemic or glomerular cause [jaundice · mouth ulcers · pallor · rash] - Suprapubic tenderness or urethral or vaginal discharge, injury, or bleeding may be found [abdominal pain · bleeding · lower abdominal pain · urethral discharge · vaginal discharge] TESTS (12) - Urinalysis is the first and most useful test; a positive dipstick needs microscopy to confirm it - At least 3 red cells per high-power field on microscopy establishes the diagnosis of hematuria - Peroxidases, semen, metronidazole, and sodium hypochlorite can cause a false-positive dipstick - Very high urinary ascorbic acid can cause a false-negative dipstick reading - Cystoscopy runs about 98% sensitive for detecting bladder cancer - Urine cytology and other biomarkers are not advised in the initial work-up of microscopic hematuria - Low-risk patients need a repeat urinalysis at 6 months, with a second one 6 months later if the first is negative - Intermediate-risk patients should get a renal ultrasound and a cystoscopy - High-risk patients need a contrast and non-contrast CT urogram plus cystoscopy - Over 25% dysmorphic red cells per HPF gives over 96% specificity for glomerulonephritis but only around 20% sensitivity - Red cell casts are rare but highly specific for a glomerular source of bleeding - Glomerular bleeding is suggested by over 500 mg of protein in a 24-hour urine collection, dysmorphic red cells, or red cell casts IF NOT THIS - what else fits (12) - Alkaptonuria, bile pigments, drug effects, or haemoglobinuria and haemolytic anaemia can discolour urine without true bleeding - Porphyria, rhabdomyolysis, phenazopyridine use, or foods such as beets and blackberries can also discolour urine without true blood - Acute flank pain with nausea and vomiting, though sometimes no symptoms at all, points toward a kidney stone - Blood at the urethral opening or an inability to pass urine points toward a urethral or bladder injury after trauma - White cells, positive nitrites, and leukocyte esterase on urinalysis plus frequency, urgency, or dysuria point toward a urinary tract infection - In an older man with known or suspected BPH, prostatic bleeding is a possible cause - Painless bleeding that is easily visible raises the most concern for a bladder, ureteral, or renal cancer - In children, post-streptococcal glomerulonephritis is the most common finding when a specific cause is identified - IgA vasculitis mainly affects children under 10 and can involve the gastrointestinal tract with bleeding - Haemolytic uraemic syndrome should be suspected in a child with hematuria plus anaemia, low platelets, or raised urea and creatinine - With protein in the urine it points at glomerular disease; with no protein and no symptoms the worry is a urothelial cancer - A strongly dipstick-positive sample with no red cells under the microscope means something else - myoglobin, haemoglobin from red cells that have burst, or another false blood Source StatPearls "Gross and Microscopic Hematuria" - disease-level clinical article Status traced to the source above 1. ENALAPRIL [1st line] Adult 2.5-5 mg once daily, titrate up to 10-20 mg once daily if persistent proteinuria or hypertension co-exists - long-term Peds Specialist pediatric nephrology referral Source Enalapril Maleate 10mg tablets SmPC section 4.2 Posology and method of administration (eMC product 561) Why Indicated specifically when microscopic haematuria is accompanied by proteinuria (>0.5 g/day) or hypertension. Caution Asymptomatic microscopic hematuria (>=3 RBCs/HPF) requires urological (cystoscopy, CT urography) and nephrological workup to rule out malignancy or glomerulonephritis. ACE inhibitors are indicated if glomerular etiology is confirmed with associated proteinuria. Monitor serum creatinine and potassium 1-2 weeks after starting. Egypt ACAPRIL 5 MG 10 TAB. ALFACURE PHAR... 6.75 EGP (0.68/unit) PRESSLIGHT 5 MG 10 TAB. EL-OBOUR 7.00 EGP (0.70/unit) RENITEC 5MG 28 TAB. GLOBAL NAPI P... 30.60 EGP (1.09/unit) 2. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Gross and Microscopic Hematuria - disease-level clinical article (microscopic- haematuria-referral-clinical.txt) Why Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen. Caution RED FLAG - The nephrology consultation criteria are dysmorphic RBCs, cellular/red-cell casts, abnormal renal function, or significant proteinuria. Red flag: development of unexplained gross hematuria automatically upgrades the patient to high-risk category requiring urgent urological work-up, even after a prior negative evaluation. RED FLAG - A risk-stratification pathway (low/intermediate/high risk by age, smoking history, RBC count, other risk factors) determines whether cystoscopy/CT urogram and referral are needed. RED FLAG - Risk-stratify before deciding how far to investigate (AUA microhaematuria criteria). LOW risk requires all of: woman under 60 or man under 40, non-smoker or under 10 pack-years, 3-10 RBC/HPF, no prior microhaematuria, no other urothelial cancer risk factor - repeat the urinalysis within 6 months. INTERMEDIATE risk is any of: woman 60 or over, man 40-59, 10-30 pack-years, 11-25 RBC/HPF, or any additional risk factor - renal ultrasound and cystoscopy are recommended. HIGH risk is any of: man 60 or over, more than 30 pack-years, more than 25 RBC/HPF, any history of gross haematuria, or prior haematuria never evaluated - these need direct cystoscopic evaluation. Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)