The American Urological Association (AUA), in partnership with the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU), released a new clinical guideline for the diagnosis, evaluation, and follow-up of microhematuria.

Concurrently, the AUA released evidence-based updates to its 2018 clinical guideline on the Surgical Management of Lower Urinary Tract Symptoms (LUTS) Attributed to Benign Prostatic Hyperplasia (BPH).

Microscopic hematuria is diagnosed when 3 or more red blood cells per high-power field in a urine specimen are visible under a microscope. It may indicate a number of conditions, such as urinary tract infection, kidney stones, or, more serious, bladder cancer. As many as 1 in 5 urology evaluations involve hematuria. Only 2 to 3 individuals out of 100 will have cancer.

“The goal of the new guideline is to provide a risk-stratified approach to hematuria evaluation based on the patient’s risk factors for urinary tract cancer,” Daniel Barocas, co-chair of the panel that developed the guideline and Associate Professor of Urology at Vanderbilt University in Nashville, Tennessee, stated in an AUA news release. “We crafted the guideline with the intention of reducing the intensity of evaluation in those at low risk for malignancy, while preserving the diagnostic sensitivity of evaluation in those at higher risk.”

After making a diagnosis, clinicians should categorize a patient as low-, intermediate- or high-risk for genitourinary malignancy and determine next steps along with the patient.

The guideline includes 22 new recommendations. The AUA highlighted 3:

Clinicians should not define microhematuria by a positive dipstick test alone. Formal microscopic evaluation of the urine is necessary.
During the initial evaluation of microhematuria, clinicians should consider such factors as genitourinary malignancy, medical renal disease, gynecologic and non-malignant genitourinary as potential causes.
After evaluation, clinicians should categorize patients based on risk to determine next steps, including repeating urinalysis, cystoscopy, renal ultrasound or axial imaging (eg, CT urogram).

The AUA’s guideline update on BPH-related LUTS includes 6 new statements and 10 revisions.

“BPH is extremely common. It affects about half of all men between ages 51 and 60 years, and up to 90% of men over age 80 years,” J. Kellogg Parsons, MD, MHS, chair of the BPH Guideline Panel stated in the AUA news release. “We believe this revised guideline will provide a useful, evidence-based clinical reference for the surgical management of male LUTS secondary to BPH.”

The guideline was amended as follows:

Guideline statement 1 was amended to include a physical examination for the initial evaluation of patients presenting with bothersome LUTS possibly due to BPH. Supporting text also was added for interpreting the results of urinalysis.

In the initial evaluation of patients presenting with bothersome LUTS possibly attributed to BPH, clinicians should take a medical history, conduct a physical examination, utilize the AUA Symptom Index (AUA-SI), and perform a urinalysis. (Clinical Principle)

Guideline statements 15, 17, 18, and 22 were amended as the retreatment and possibility of treatment failure aspects of these statements are now covered under a new statement 6 under evaluation and preoperative testing. It reads:

Clinicians should inform patients of the possibility of treatment failure and the need for additional or secondary treatments when considering surgical and minimally-invasive treatments for LUTS secondary to BPH. (Clinical Principle)

Statement 16 under prostatic urethral lift (PUL) was amended. This statement now supports PUL use to improve erectile and ejaculatory function and reads as follows:

PUL may be offered to eligible patients who desire preservation of erectile and ejaculatory function. (Conditional Recommendation; Evidence Level: Grade C)

An update to guideline statement 19 on water vapor thermal therapy was made to reflect newly published research. The new statement reads:

Water vapor thermal therapy may be offered to eligible patients who desire preservation of erectile and ejaculatory function. (Conditional Recommendation; Evidence Level: Grade C)

An update to guideline statement 21 pertaining to laser enucleation was made to reflect newly published research. The new statement reads:

Clinicians should consider holmium laser enucleation of the prostate (HoLEP) or thulium laser enucleation of the prostate (ThuLEP), depending on their expertise with either technique, as prostate size-independent options for the treatment of LUTS attributed to BPH. (Moderate Recommendation; Evidence Level: Grade B)

Guideline statement 23 on prostate artery embolization (PAE) was amended to include the following phrase: “PAE for the treatment of LUTS secondary to BPH is not supported by current data and trial designs, and benefit over risk remains unclear.”