To evaluate adherence to the 2025 AUA/SUFU microhematuria (MH) guideline, which requires confirmatory microscopic urinalysis (MUA ≥3 RBC/HPF) after a positive dipstick.

TriNetX Research Network data (109 US health systems) were queried for adults aged 18-90 years with an initial positive dipstick from July 2020 to February 2025. Patients with gross hematuria, urinary tract infections, and kidney and/or ureteral calculi, cystitis, proteinuria, dysuria, and pregnancy diagnoses were excluded. Patients were stratified into three cohorts: no MUA, negative MUA, and positive MUA. We recorded the use of computed tomography (CT) urography, magnetic resonance imaging (MRI) urography, renal ultrasound, or cystoscopy within 6 months of positive dipstick.

Among 37,300 eligible patients, 25,904 (69%) received MUA and 11,396 (31%) did not. MUA was positive in 9913 cases (38%) and negative in 15,991 (62%). Downstream testing followed 7.5% of dipstick-only cases, 16.1% of negative-MUA cases, and 16.3% of positive-MUA cases. In total, 855 procedures were performed without any MUA and 2575 after a negative MUA, resulting in potentially avoidable charges. Conversely, 84% of patients with confirmed MH underwent no further evaluation.

31% of positive urine dipstick results were not followed by a confirmatory MUA, and 84% of patients with a positive MUA underwent no additional evaluation. These shortfalls point to gaps in the implementation of guideline-based care for MH. Future work should test targeted decision-support tools and simplified referral pathways to improve adherence and patient outcomes.