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We thank the correspondents for their contributions and additional comments with regard to investigating hematuria. It is important to consider—in addition to the potential causes of hematuria listed in Figure 1 (in the article)—further, even rare, causes. These include gynecological disorders, such as endometriosis, which can manifest in the urogenital tract, or urogenital atrophy, which may be accompanied by microhematuria that is reversible by applying topical/local estrogen. Furthermore, the medical history should help to exclude pseudohematuria as a result of the consumption of certain foods, as well as owing to false-positive results from the often highly sensitive rapid urine tests (1).
The revised version of the practice recommendations of the German College of General Practitioners and Family Physicians (DEGAM) has recently been published (2). The recommendations are based on rapid urine testing using a test strip. On the basis of comorbidities and established risk factors, the recommendation is to stratify patients for further investigation, in order to avoid overdiagnosis. In tandem, patient information on hematuria was developed and made available. This information may empower patients to make their own decision regarding referral to a urologist and undergoing further diagnostic tests.
We wish to add to Dr. Mainz’s comments that we do not recommend “opportunistic screening” for hematuria. But if we already are in possession of positive findings from test strips then we think that—in view if the high rate of false-positives mentioned earlier—it is important and logical to confirm the hematuria by using sediment analysis before undertaking further diagnostic tests. Pertinent diagnoses should not be missed even if their prevalence may be low. According to recent study data, in many patients, non-invasive ultrasound diagnostics—if indicated in combination with urethrocystoscopy—provides a high degree of certainty in ruling out malignant causes (3). A graded/stepwise, risk adapted approach can help reduce overdiagnosis using complex medical apparatus and incurring unnecessarily high costs.
Prof. Dr. med. Christian Bolenz
Klinik für Urologie und Kinderurologie, Universitätsklinikum Ulm
Prof. Dr. med. Bernd Schröppel
Klinik für Innere Medizin 1, Sektion Nephrologie, Universitätsklinikum Ulm
PD Dr. med. Andreas Eisenhardt
Praxisklinik Urologie Rhein Ruhr, Mühlheim an der Ruhr
Klinik für Urologie, Kinderurologie und Uroonkologie, Universitätsklinikum Essen
Prof. Dr. med. Bernd J. Schmitz-Dräger
Sektion Urologische Onkologie, Urologische Klinik St. Theresienkrankenhaus, Nürnberg und Urologische Klinik und Kinderklinik der Universität Erlangen
Prof. Dr. med. Marc-Oliver Grimm
Klinik und Poliklinik für Urologie, Universitätsklinikum Jena
Conflict of interest statement
The authors declare that no conflict of interest exists.
|1.||Rao PK, Gao T, Pohl M, Jones JS: Dipstick pseudohematuria: unnecessary consultation and evaluation. J Urol 2010; 183: 560–4 CrossRef MEDLINE|
|2.||Mainz A: Nicht-sichtbare Hämaturie – weniger ist mehr! Neue S1-Handlungsempfehlungen der Deutschen Gesellschaft für Allgemeinmedizin und Familienmedizin (DEGAM). Z Allg Med 2014; 90: 58.|
|3.||Tan WS, Sarpong R, Khetrapal P, et al.: Can renal and bladder ultrasound replace CT urogram in patients investigated for microscopic hematuria? J Urol 2018; pii: S0022–5347.|
|4.||Bolenz C, Schröppel B, Eisenhardt A, Schmitz-Dräger BJ, Grimm MO: The investigation of hematuria. Dtsch Arztebl Int 2018; 115: 801–7 VOLLTEXT|