定义
离心后，尿沉渣镜检每高倍视野通常包含2~3个红细胞。[1]Grossfeld GD, Litwin MS, Wolf JS, et al. Evaluation of asymptomatic microscopic hematuria in adults: the American Urological Association best practice policy - part I: definition, detection, prevalence and etiology. Urology. 2001;57:599-603.http://www.ncbi.nlm.nih.gov/pubmed/11306356?tool=bestpractice.com[2]Wollin T, Laroche B, Psooy K. Canadian guidelines for the management of asymptomatic microscopic hematuria in adults. Can Urol Assoc J. 2009:3;77-80.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2645872/http://www.ncbi.nlm.nih.gov/pubmed/19293985?tool=bestpractice.com[3]Tomson C, Porter T. Asymptomatic microscopic or dipstick haematuria in adults: which investigations for which patients? A review of the evidence. BJU Int. 2002;90:185-198.http://www.ncbi.nlm.nih.gov/pubmed/12133052?tool=bestpractice.com 目前共识主张，在 3 次尿样本中出现 2 次及以上≥3 RBC/HPF（每高倍视野含有≥3 个红细胞）即提示镜下血尿 (NVH)。然而，如果患者只在 1 次样本中出现更少量红细胞，也应对有恶性肿瘤风险的患者进行全面检查，因为肿瘤可能间歇性出血。[1]Grossfeld GD, Litwin MS, Wolf JS, et al. Evaluation of asymptomatic microscopic hematuria in adults: the American Urological Association best practice policy - part I: definition, detection, prevalence and etiology. Urology. 2001;57:599-603.http://www.ncbi.nlm.nih.gov/pubmed/11306356?tool=bestpractice.com[3]Tomson C, Porter T. Asymptomatic microscopic or dipstick haematuria in adults: which investigations for which patients? A review of the evidence. BJU Int. 2002;90:185-198.http://www.ncbi.nlm.nih.gov/pubmed/12133052?tool=bestpractice.com
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意义
尽管与恶性肿瘤的关系不如肉眼血尿密切，镜下血尿也可能是癌症的信号。[4]National Institute for Health and Care Excellence. Suspected cancer: recognition and referral. July 2017 [internet publication].https://www.nice.org.uk/guidance/ng12 然而，约一半的镜下血尿是特发性的。[2]Wollin T, Laroche B, Psooy K. Canadian guidelines for the management of asymptomatic microscopic hematuria in adults. Can Urol Assoc J. 2009:3;77-80.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2645872/http://www.ncbi.nlm.nih.gov/pubmed/19293985?tool=bestpractice.com[3]Tomson C, Porter T. Asymptomatic microscopic or dipstick haematuria in adults: which investigations for which patients? A review of the evidence. BJU Int. 2002;90:185-198.http://www.ncbi.nlm.nih.gov/pubmed/12133052?tool=bestpractice.com[5]Hiatt RA, Ordonez JD. Dipstick urinalysis screening, asymptomatic microhematuria, and subsequent urological cancers in a population-based sample. Cancer Epidemiol Biomarkers Prev. 1994;3:439-443. [Published correction appears in Cancer Epidemiol Biomarkers Prev. 1994;3:523.]http://cebp.aacrjournals.org/cgi/reprint/3/5/439http://www.ncbi.nlm.nih.gov/pubmed/7848421?tool=bestpractice.com[6]Edwards TJ, Dickinson AJ, Natale S, et al. A prospective analysis of the diagnostic yield resulting from 4020 patients at a protocol-driven haematuria clinic. BJU Int. 2006;97:301-305.http://www.ncbi.nlm.nih.gov/pubmed/16430634?tool=bestpractice.com[7]Cohen RA, Brown RS. Microscopic hematuria. N Engl J Med. 2003;348:2330-2338.http://www.ncbi.nlm.nih.gov/pubmed/12788998?tool=bestpractice.com[8]Chou R, Dana T. Screening adults for bladder cancer: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;5:153:461-468.http://www.ncbi.nlm.nih.gov/pubmed/20921545?tool=bestpractice.comAUA: diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults
病史
最重要的一项初步诊断步骤是详细的病史询问，其目的是为了确定恶性肿瘤的危险因素。病史也可能提示不太严重的原因(例如：近期体育锻炼或性活动、尿路感染、月经)。
恶性肿瘤风险
泌尿系恶性肿瘤风险会随以下因素而升高：年龄>40岁、吸烟、放射性物质接触史、特定的职业暴露（染料、苯系物、芳香胺）、药物（如非那西丁，仅见于日本)、环磷酰胺和马兜铃酸（见于部分中草药成分的减肥药）。[7]Cohen RA, Brown RS. Microscopic hematuria. N Engl J Med. 2003;348:2330-2338.http://www.ncbi.nlm.nih.gov/pubmed/12788998?tool=bestpractice.com 如果怀疑是恶性肿瘤，对于高风险人群，需要对整个尿路进行检查，包括上尿路影像学检查和下尿路的膀胱镜检查。[1]Grossfeld GD, Litwin MS, Wolf JS, et al. Evaluation of asymptomatic microscopic hematuria in adults: the American Urological Association best practice policy - part I: definition, detection, prevalence and etiology. Urology. 2001;57:599-603.http://www.ncbi.nlm.nih.gov/pubmed/11306356?tool=bestpractice.com[7]Cohen RA, Brown RS. Microscopic hematuria. N Engl J Med. 2003;348:2330-2338.http://www.ncbi.nlm.nih.gov/pubmed/12788998?tool=bestpractice.com[9]Messing EM, Madeb R, Young T, et al. Long-term outcome of hematuria home screening for bladder cancer in men. Cancer. 2006;107:2173-2179.http://onlinelibrary.wiley.com/doi/10.1002/cncr.22224/fullhttp://www.ncbi.nlm.nih.gov/pubmed/17029275?tool=bestpractice.com[10]Alishahi S, Byrne D, Goodman CM, et al. Haematuria investigation based on a standard protocol: emphasis on the diagnosis of urological malignancy. J R Coll Surg Edinb. 2002;47:422-427.http://www.ncbi.nlm.nih.gov/pubmed/11874263?tool=bestpractice.com[11]Froom P, Ribak J, Benbassat J. Significance of microhaematuria in young adults. BMJ. 1984;288:20-22.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1444134/pdf/bmjcred00482-0026.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/6418299?tool=bestpractice.com[12]Topham PS, Jethwa A, Watkins M, et al. The value of urine screening in a young adult population. Fam Pract. 2004;21:18-21.http://fampra.oxfordjournals.org/cgi/content/full/21/1/18http://www.ncbi.nlm.nih.gov/pubmed/14760038?tool=bestpractice.com[13]Mishra VC, Rowe E, Rao AR, et al. Role of i.v. urography in patients with haematuria. Scand J Urol Nephrol. 2004;38:236-239.http://www.ncbi.nlm.nih.gov/pubmed/15204378?tool=bestpractice.com 相比之下，低风险患者的检查可以更专注于可能的病因，而不必对整个尿路进行调查。英国国家卫生与临床优化研究所推荐，若年龄≥60 岁的患者有原因不明的 NVH 以及尿痛或血检显示白细胞计数升高，则应在 2 周内按照疑似膀胱癌的转诊方式进行预约转诊。[4]National Institute for Health and Care Excellence. Suspected cancer: recognition and referral. July 2017 [internet publication].https://www.nice.org.uk/guidance/ng12
分类标准
根据解剖部位来考虑出血来源提供了一种有序的方法。上尿路包括肾脏(肾小球或非肾小球性)和输尿管，剩余的部分为下尿路。这些分类标准在病史询问和体格检查时有很大价值，同时，这也可体现在安排诊断性检查时，因为没有一项诊断性检查能完全评估整个尿路。
诊断性检查
诊断性检查必须首先确认 NVH 的存在。其次，检验应可以区别上尿路肾小球源性血尿与其他类型血尿，进而才能进行更为精确的处理。但是上尿路和下尿路的诊断性检查（影像学和膀胱镜检查）对伴有泌尿系统恶性肿瘤危险因素的患者仍有必要。在研究试验中，尿肿瘤标志物对诊断泌尿系统肿瘤并未表现出足够的特异性。然而，这些标志物也许可以在评估治疗效果和检测治疗后复发中发挥作用。[14]Ecke TH. Focus on urinary bladder cancer markers: a review. Minerva Urol Nefrol. 2008;60:237-246.http://www.ncbi.nlm.nih.gov/pubmed/18923360?tool=bestpractice.com[15]van Rhijn BW, van der Poel HG, van der Kwast TH. Cytology and urinary markers for the diagnosis of bladder cancer. Eur Urol Suppl. 2009;8:535-566.
筛查
NVH 患者最常发生的癌症是膀胱移行细胞癌。[6]Edwards TJ, Dickinson AJ, Natale S, et al. A prospective analysis of the diagnostic yield resulting from 4020 patients at a protocol-driven haematuria clinic. BJU Int. 2006;97:301-305.http://www.ncbi.nlm.nih.gov/pubmed/16430634?tool=bestpractice.com[9]Messing EM, Madeb R, Young T, et al. Long-term outcome of hematuria home screening for bladder cancer in men. Cancer. 2006;107:2173-2179.http://onlinelibrary.wiley.com/doi/10.1002/cncr.22224/fullhttp://www.ncbi.nlm.nih.gov/pubmed/17029275?tool=bestpractice.com[16]Friedman GD, Carroll PR, Cattolica EV, et al. Can hematuria be a predictor as well as a symptom or sign of bladder cancer? Cancer Epidemiol Biomarkers Prev. 1996;5:993-996.http://cebp.aacrjournals.org/cgi/reprint/5/12/993http://www.ncbi.nlm.nih.gov/pubmed/8959322?tool=bestpractice.com[17]Sugimura K, Ikemoto S, Kawashima H, et al. Microscopic hematuria as a screening marker for urinary tract malignancies. Int J Urol. 2001;8:1-5.http://www.ncbi.nlm.nih.gov/pubmed/11168689?tool=bestpractice.com[18]Jones R, Latinovic R, Charlton J, et al. Alarm symptoms in early diagnosis of cancer in primary care: cohort study using general practice research database. BMJ. 2007;334:1040.http://www.bmj.com/cgi/content/full/334/7602/1040http://www.ncbi.nlm.nih.gov/pubmed/17493982?tool=bestpractice.com 据美国预防服务工作组估计，NVH 对膀胱癌的阳性预测值为 5%~8%，不建议进行常规筛查。[8]Chou R, Dana T. Screening adults for bladder cancer: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;5:153:461-468.http://www.ncbi.nlm.nih.gov/pubmed/20921545?tool=bestpractice.com[19]Nielsen M, Qaseem A; High Value Care Task Force of the American College of Physicians. Hematuria as a marker of occult urinary tract cancer: advice for high-value care from the American College of Physicians. Ann Intern Med. 2016;164:488-497.http://annals.org/article.aspx?articleid=2484287http://www.ncbi.nlm.nih.gov/pubmed/26810935?tool=bestpractice.com尿路肿瘤的鉴别：有中等证据表明，通过对血尿的筛查确定泌尿系肿瘤是无益的。[5]Hiatt RA, Ordonez JD. Dipstick urinalysis screening, asymptomatic microhematuria, and subsequent urological cancers in a population-based sample. Cancer Epidemiol Biomarkers Prev. 1994;3:439-443. [Published correction appears in Cancer Epidemiol Biomarkers Prev. 1994;3:523.]http://cebp.aacrjournals.org/cgi/reprint/3/5/439http://www.ncbi.nlm.nih.gov/pubmed/7848421?tool=bestpractice.com[9]Messing EM, Madeb R, Young T, et al. Long-term outcome of hematuria home screening for bladder cancer in men. Cancer. 2006;107:2173-2179.http://onlinelibrary.wiley.com/doi/10.1002/cncr.22224/fullhttp://www.ncbi.nlm.nih.gov/pubmed/17029275?tool=bestpractice.com[12]Topham PS, Jethwa A, Watkins M, et al. The value of urine screening in a young adult population. Fam Pract. 2004;21:18-21.http://fampra.oxfordjournals.org/cgi/content/full/21/1/18http://www.ncbi.nlm.nih.gov/pubmed/14760038?tool=bestpractice.com[20]Feldstein MS, Hentz JG, Gillett MD, et al. Should the upper tracts be imaged for microscopic haematuria? BJU Int. 2005;96:612-617.http://www.ncbi.nlm.nih.gov/pubmed/16104920?tool=bestpractice.com[21]Yamagata K, Takahashi H, Tomida C, et al. Prognosis of asymptomatic hematuria and/or proteinuria in men. High prevalence of IgA nephropathy among proteinuria patients found in mass screening. Nephron. 2002;91:34-42.http://www.ncbi.nlm.nih.gov/pubmed/12021517?tool=bestpractice.com受试者＜200名的随机对照临床试验（RCT）、受试者＞200名且方法学存在缺陷的随机对照临床试验（RCT）、方法学存在缺陷的系统评价或者高质量的观察性（队列）研究。 一项针对肾肿瘤患者的病例对照研究发现单次尿样本中出现≥4 RBC/HPF 或≥5 RBC/HPF 的患者伴有 NVH 的可能性是无恶性肿瘤的患者的两倍（≥4 RBC/HPF 的比值比为 2.2；≥5 RBC/HPF 的比值比为 2.0)。[20]Feldstein MS, Hentz JG, Gillett MD, et al. Should the upper tracts be imaged for microscopic haematuria? BJU Int. 2005;96:612-617.http://www.ncbi.nlm.nih.gov/pubmed/16104920?tool=bestpractice.com
