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I have a review article from Medical clinics of N America which you may find on google and I am happy to e-mail to anyone who wants it--about 240KB. Anyway, a few snippets. American urologists say, some of them anyway, that micro haem in over 40s is malignant until proven otherwise. Full assessment including urine cytology, imaging and cystoscopy reveals a cause in up to 100% (but not in my experience, here). Up to half have some renal lesion on biopsy--that would be those left without identifiable cause on the urology workup. There is some argument about using microscopy to confirm and they talk about how malignancies may bleed only intermittently and rates of those with dipstick haematuria. In actual practice it is nowhere near as outre as it may sound from the above and standard workup seems to be pretty much what our local urologists do. Although the question on this thread is more one of which patients do we refer in the first place? Your local urology dept may have a view on this and may even give you their protocol--though it will of course be a bit skewed because it is aimed at patients some other doctor is worried enough about to refer. Declan