Practice patterns in the evaluation of microhematuria in urogynecology

Objectives: This study aims to assess common practice patterns of urogynecologists in the evaluation of microscopic hematuria, and to determine how closely urogynecologists adhere to evidence-based management guidelines from the American Urological Association (AUA), the American College of Obstetricians and Gynecologists (ACOG), and the American Urogynecologic Society (AUGS).

Methods: An anonymous electronic survey was distributed to 1000 physician and non-physician members of AUGS to assess their adherence to AUA and ACOG/AUGS guidelines when managing patients with microhematuria. Survey questions were designed to elicit respondents' various training backgrounds, methods of microhematuria detection and evaluation, and risk stratification algorithms to guide these methods. Data was interpreted using descriptive statistics to distinguish characteristics and practices of providers who follow AUA guidelines from characteristics and practices of providers who follow ACOG/AUGS guidelines.

Results: Of the 115 survey respondents, 91 followed AUA guidelines, while 24 followed ACOG/AUGS guidelines. Urology-trained providers were more likely to follow AUA guidelines (90%) than OBGYN-trained providers (76.5%). In standardized clinical vignettes, providers following AUA guidelines were able to more consistently correctly identify the guideline-recommended next step in evaluation when compared to respondents following ACOG/AUGS guidelines. Respondents were also more likely to report a higher rate of urothelial cancer detection when following AUA guidelines. Genitourinary atrophy, pelvic organ prolapse, fibroids and recent urogenital surgery or instrumentation were cited as factors that, when present, would lead providers to defer further evaluation of microhematuria in low-risk patients. Since the introduction of the AUA's 2020 guidelines, many respondents confirmed that they have changed their methods of evaluating microhematuria. Common changes in practice include discontinuation of the use of urine cytology for microhematuria evaluation. Furthermore, many providers noted a decrease in the frequency with which patients undergo CT Urogram and cystoscopy since incorporating new risk stratification protocols that recommend deferral of these costly, invasive tests for low-risk patients.

Conclusions: The majority of urogynecology providers in practice follow the 2020 AUA guidelines on the evaluation of microhematuria. Urology-trained providers are more likely to follow AUA guidelines than OBGYN-trained providers. This survey revealed that providers are also able to more reliably and consistently adhere to AUA guidelines than ACOG/AUGS guidelines in clinical practice. All respondents who identified a perceptible increase in the rate of detection of urothelial cancer since updating their microhematuria evaluation methods reported following the updated AUA guidelines. The results from this survey highlight a need for standardization of the algorithm for microhematuria evaluation. Further investigation is also warranted to determine the utility and cost-effectiveness of microhematuria evaluation tools in patients with concomitant, and potentially confounding, benign gynecologic conditions such as vulvovaginal atrophy, pelvic organ prolapse, and abnormal uterine bleeding.