Many serious and potentially treatable diseases of the urinary tract may have haematuria as their only manifestation. However, asymptomatic microscopic haematuria detected by dipstick testing may be seen in up to 16% of screening populations. The great majority of such cases will have no sinister underlying cause, particularly in those under 40 years of age, and so the schedule of further investigations, some of which may be invasive, time-consuming and expensive, needs to be rationalised. In addition, the increasing popularity of 'fast track' clinics for the investigation of haematuria enhances the need for a clear strategy of investigation. Analysis of the epidemiology of asymptomatic haematuria and its causes combined with a consideration of the risk-benefit profile of the available investigations, makes it possible to set out an algorithm for the initial management of this common finding. Careful clinical assessment and basic laboratory tests for renal function, analysis of the urinary sediment and cytological examination of the urine are followed by ultrasound and plain radiography of the urinary tract. Flexible cystoscopy under local anaesthetic is central to the algorithm in patients of all ages. The importance of a nephrological opinion and consideration of renal biopsy, especially in younger patients with other evidence of glomerular disease, is stressed. The role of intravenous urography in excluding pathology of the upper urinary tract, especially in patients over the age of 40, is also considered.
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