Navigating the 2025 Microhematuria Guidelines: Key Updates for Clinicians

The American Urological Association, in collaboration with the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction, has released a 2025 amendment to its guideline on the evaluation of microhematuria, refining how clinicians assess cancer risk while deliberately scaling back unnecessary testing in patients with very low malignancy probability.

The update builds on the risk-stratified framework introduced in 2020, but incorporates new evidence that allows for more precise categorization of patients and clearer guidance on when invasive evaluation is—and is not—warranted. At its core, the revision seeks to balance timely detection of genitourinary malignancy against the cumulative burden of cystoscopy, imaging, radiation exposure, and incidental findings.

One of the most notable changes is the formal adoption of the term “low/negligible risk,” reflecting data showing that cancer detection rates in this group are exceedingly low. Patients in this category, which includes many younger individuals and women without additional risk factors, are no longer directed toward immediate cystoscopy or imaging. Instead, the guideline recommends repeat urinalysis within six months, reserving further evaluation for those with persistent microscopic hematuria.

Risk stratification itself has been refined, particularly for women. The updated guideline recognizes sex-specific differences in malignancy risk, categorizing women under 60 years of age as low/negligible risk in the absence of other concerning features. Importantly, women are no longer classified as high risk based on age alone. Across all patients, risk assignment now integrates degree of microscopic hematuria, age thresholds that differ by sex, smoking history, and additional urothelial cancer risk factors such as occupational exposures, prior pelvic radiation, or family history.

For patients deemed intermediate risk, the guideline continues to recommend cystoscopy and renal ultrasound as standard evaluation. However, a new preference-sensitive pathway acknowledges that some patients may wish to defer cystoscopy after appropriate counseling. In these cases, urine cytology or validated urine-based tumor markers may be used as adjuncts to risk assessment, though renal and bladder ultrasound remains recommended. Persistent hematuria on follow-up testing should prompt cystoscopy.

High-risk patients continue to warrant comprehensive evaluation, including cystoscopy and axial upper tract imaging. Multiphasic CT urography remains the preferred modality when there are no contraindications, given its superior visualization of both renal parenchyma and urothelium. For patients who cannot undergo CT urography, MR urography or alternative imaging strategies are outlined.

While the amendment introduces a clearer role for urine-based tumor markers, it stops short of endorsing their routine use across all risk groups. The guideline specifically advises against using biomarkers to determine whether cystoscopy should be performed in low/negligible- or high-risk patients during initial evaluation, reinforcing their role as selective tools rather than universal gatekeepers.

Taken together, the 2025 update reflects a maturation of the microhematuria algorithm, emphasizing objective risk factors, repeat testing for very low-risk patients, and targeted use of diagnostic resources. By narrowing intensive evaluation to those most likely to benefit, the guideline aims to reduce procedural burden without compromising cancer detection—an approach likely to reshape referral patterns, outpatient workflows, and shared decision-making conversations in everyday practice.