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Three Part Question

In [adults with atraumatic asymptomatic microscopic haematuria] is [immediate GUS investigation better than delayed investigation or no investigation at all] at [detecting significant underlying pathology]?

Clinical Scenario

A 70 year old man presents to the Emergency Department with a tummy ache. As part of your examination you dipstick his urine and find that he has microscopic haematuria. At the end of your history, examination and investigation you find that he is constipated. You conclude that the haematuria was an incidental finding. You wonder if further investigation of the haematuria would uncover significant underlying pathology. The man's 20 year old grandson who is accompanying him tells you that after his GP dipsticked his urine and found the same thing as part of a check-up he was referred for further investigation at the hospital.

Search Strategy

Medline using the OVID interface - 1966 to June Week 1 2005
Embase - 1980 to 2005 Week 24
CINAHL - 1982 to June Week 1 2005
Cochrane Library - Issue 2 2005
(exp. HEMATURIA OR haematuria.mp) AND (atraumatic.mp. OR asymptomatic.mp. OR microscopic.mp.) AND (genitourinary system invesitgation.mp. OR exp. CYSTOSCOPY/ OR renal ultraso$.mp. OR exp. URINALYSIS/ OR KUB.mp. OR exp. UROGRAPHY OR intravenous urography.mp. OR intravenous pyelography.mp. OR IVU.mp. OR IVP.mp. OR exp Radiography, Abdominal/ or ABDOMINAL X-RAY.mp.)
Limit to (Humans, English Language, Adults (19 and over))

Search Outcome

Medline - 216 papers found of which 5 were relevant
Embase - no additional relevant papers
CINAHL - no additional relevant papers
Cochrane Library - no additional relevant papers
1 additional paper found by a manual search of references

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hiatt R, Ordonez JD 1994 USA	20981 patients (men aged>35 years and women aged>55 years) selected by a computer-stored file. All had a Personal Health Appraisal from a prepaid health plan in 1980. After exclusions for possible existing conditions which might cause haematuria patients were dipsticked and the two patient groups remaining were 19875 (no haematuria) and 598 (asymptomatic microscopic haematuria)	Retrospective cohort study	Number of serious outcomes (urinary tract cancers) discovered in the following 3 years in patient group with AMH (predictive value of a single specimen with microhaematuria)	3 (0.5%)	Only one single dipstick test used to detect AMH. Some demographic groups not included.
			Number of serious outcomes (urinary tract cancers) discovered in the following 3 years in patient group with no haematuria	102 (0.5%)
			For indicating urological cancers	Sensitivity of AMH = 2.9%
				Specificity of AMH = 96.7%
Yasumasu et al 1994 Japan	355 patients (135 men, 220 women) with AMH visiting hospital between Jan 1986 and Dec 1990	Retrospective cohort study	Number of urologic abnormalities on investigation	69 (19.4%) including 1 malignancy (0.3%)	Included patients under 18 years of age (16 in total). Patients were included regardless of proteinuria, pyuria and/or bacteruria accompanying their hameaturia. Definition of degree of haematuria required for inclusion in the study not stated.
			Rate of urologic abnormalities in subjects under 40 years	7/54 (13%)
			Rate of urologic abnormalities in subjects over 40 years	62/301 (20.6%) including 1 malignancy
Khadra et al 2000 UK	1930 pateints enrolled from a hematuria clinic between Oct 1994 and March 1997. 1194 males, 736 females, mean age 58 years (range 17 - 96). Number of patients with microscopic haematuria 982.	Prospective study	Proportion of patients with AMH found to have significant disease	18.7%	Includes subjects under 18 years of age. Definition of 'significant disease' not stated
			Total rate of cancer found in patients with AMH	51/982 (5.2%)
			Rate of cancer found in subjects with AMH under 40 years	1/143 (0.7%)
			Rate of cancer found in subjects with AMH greater than 40 years	50/839 (6%)
Suzuki et al 1999 Japan	263 patients (83 males, 180 females) between Jan 1993 and March 1996 showing haematuira on dipstick on annual health screening examination. Average age was 54.7 (range 16-92) 79 patients were younger than 40 years.	Prospective cohort study	Highly significant lesions (likely to be a threat to life without immediate treatment) detected on evaluation	18 (6.8%) (including 8 bladder cancers (3%) where all subjects were greater than 40 years of age)	Sensitivities and specificities not recorded for any outcome other than bladder cancer. Only microscopic haematuria included.
			Moderately significant (no threat to life, but where haematuria was expected to resolve with treatment) lesions detected on evaluation	52 (19.8%)
Murakami et al 1990 Japan	1034 adults with asymptomatic microhaematuria noted after annual health checks. Average patient age 53.4 years. Male:female ratio approx. 1:3.	Prospective cohort study	highly significant lesions detected	30 (2.9%) consisting of 24 malignancies and 6 glomerulopathic conditions that may progress to renal failure	No breakdown of incidence in different demographic groups except a statement that all bladder cancers were in over 40 year olds. Predominance of women in this study may be significant since the findings showed a higher incidence of significant lesions in the men
			moderately significant lesions	195 (18.9%)
Sugimura et al 2001 Japan	823 asymptomatic adults with microhaematuria presenting between May 1993 and Nov 1998.	Retrospective cohort study	Positive predictive value of AMH for bladder carcinoma	1.7% (14 cases)	Due to retrospective nature of study the diagnostic process for each patient depended on the decision of the particular urologist in charge of the patient. Full results not broken down according to demographics (age, gender)
			Positive predictive value of AMH for ureteral/renal pelvic carcinoma	0.4% (3 cases)
			Positive predictive value of AMH for renal cell carcinoma	0.2% (2 cases)
			Total PPV of AMH for urological cancers	2.9% (since 5 cases of prostate cancer were diagnosed incidentally)
			If results are limited to men aged over 50 years, PPV for urothelial carcinomas and for total urologic cancers	6.2% (14/225) and 9.3% respectively

Comment(s)

Overall rates of pathology are lower in those under 40 years of age. None of the papers found directly answered the question regarding the timescale on which the investigations should be carried out. However, an answer was found as to whether investigation should be carried out at all. In 2 studies only malignancy was considered to be a significant outcome. However, when all pathological outcomes are considered a conclusion can be drawn from the evidence.

Clinical Bottom Line

Adult patients presenting to the Emergency Department with atraumatic, asymptomatic, microscopic haematuria require full genitourinary system investigation.

References

1. Hiatt R, Ordonez JD Dipstick urinalysis screening, asymptomatic microhematuria, and subsequent urological cancers in a population-based sample Cancer Epidemiology, Biomarkers & Prevention Vol. 3, 439-443, July/August 1994
2. Yasumasu T, Koikawa Y, Uozumi J, Ueda T, Kumazawa J Clinical study of asymptomatic microscopic haematuria International Urology and Nephrology 26 (1), pp. 1-6 (1994)
3. Khadra MH, Pickard RS, Charlton M, Powell PH, Neal DE A prospective analysis of 1,930 patients with hematuria to evaluate current diagnostic practice J Urol 2000;163:524-7
4. Suzuki Y, Sasagawa I, Abe Y, Suzuki H, Kubota Y, Nakada T, Ohji H Indication of cystoscopy in patients with asymptomatic microscopic haematuria Scandanavian Journa of Urology & Nephrology 34(1):51-4, 2000 Feb
5. Murakami S, Igarashi T, Hara S, Shimazaki J Strategies for asymptomatic microscopic hematuria: a prospective study of 1034 patients Journal of Urology 144(1):99-101, 1990 Jul.
6. Sugimura K, Ikemoto S-I, Kawashima H, Nishisaka N, Kishimoto T Microscopic hematuria as a screening marker for urinary tract malignancies Intertational Journal of Urology (2001) 8, 1-5