ACRIDINE ORANGE FLUORESCENE EXFOLIATIVE URINARY CYTOLOGY IS A GOLD STANDARD FOR THE DIAGNOSIS OF BLADDER CARCINOMA

Abstract

INTRODUCTION AND OBJECTIVES: The prompt workup of hematuria can lead to early diagnosis of significant serious conditions of the GU tract. The benefits of early detection of hematuria include not only the early discovery of significant benign and malignant conditions, but also reduced mortality from bladder cancer in screened populations. However, there is often a delay in the evaluation of patients with hematuria. METHODS: An anonymous 9 question online survey was sent to primary care providers within the VA system. We evaluated hematuria practice patterns amongst primary care physicians, nurse practitioners, and physician assistants. We attempted to determine the thresholds for “significant hematuria”, further diagnostic testing and specialist referral. RESULTS: There were 648 responses from physicians (64%), nurse practitioners (30%), and physician assistants (7%). Routine yearly urinalysis in all asymptomatic patients was performed by 343 (53%) providers. 12% never checked a routine yearly urinalysis and 34% checked only in patients with specific conditions such as diabetics and smokers. The most commonly accepted definition of hematuria was >5 RBC/HPF (61%); 18% (117) considered any RBC/HPF as hematuria, 9% (55) considered it a positive dipstick, and 4% (27) considered only gross hematuria to be significant. As the “initial step” for microscopic hematuria, most providers would either repeat the urinalysis or send the urine for culture (67% and 17%, respectively). The most commonly utilized “next steps” for microscopic hematuria were imaging studies (36%), urine culture (19%), urine cytology (17%), and referral to urology (14%). For gross hematuria the most common “initial steps” were imaging studies (45%), urine culture (20%), and urology referral (12%). The most frequent “next steps” for gross hematuria were referral to a urologist (59%) and imaging studies (23%). The initial imaging studies of choice were renal ultrasound (35%), CT scan with and without I.V. contrast (20%), and intravenous pyelogram (18%). CONCLUSIONS: There is a wide range in the definition and evaluation of both microscopic and gross hematuria in the primary care setting. The lack of standardized definitions and protocols for screening and workup may in some cases delay the diagnosis of significant GU pathology resulting in adverse outcomes. The data provides a platform on which to develop educational materials for primary care providers.