Contemporary Microhematuria Evaluation in Veterans: Cancer Detection and Resource Utilization

Microhematuria evaluation remains a common reason for urologic referral in the Veterans Affairs (VA) system, yet real-world practice patterns in this population are not well defined. In our study, we found that although most Veterans with microhematuria were referred to urology and underwent cystoscopy, bladder cancer detection was rare and occurred exclusively in those with the highest microhematuria and age-based risk. This highlights a growing disconnect between guideline-based recommendations and the clinical reality of caring for an older, comorbidity-heavy Veteran population.

A key observation was the potential overuse of invasive testing in low-risk Veterans as more than half of referrals occurred in patients with only 3–10 red blood cells per high-powered field (RBC/hpf), and nearly all low-risk patients who had a repeat urinalysis no longer demonstrated hematuria. These findings support more selective referral strategies and greater use of repeat testing before specialist evaluation, which aligns with recent American Urological Association (AUA) guideline updates.

Our cost analysis also suggests that raising diagnostic thresholds for microhematuria evaluation could substantially reduce resource use within the VA, where fixed annual budgets and high utilization make efficiency especially important. Although this was a single-center study with limited cancer events, the results support the need for VA-specific risk stratification tools that balance cancer detection with efficient resource use.

Future work should validate these findings across multiple VA centers, incorporate additional risk factors such as smoking and occupational exposures, and evaluate whether decision-support tools or urinary biomarkers can help better target evaluation to those at highest risk.

Written by: Krishay Sridalla, BA, MD Student, Class of 2028, Northwestern University, Feinberg School of Medicine, Chicago, Illinois

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