Clinical Commander

All dossiers
symptom.hematuria.v1

Hematuria (gross / microscopic)

symptomacutesubacuteundifferentiatedadultoutpatientacuteinpatient
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Phase C shard-3-neuro-sym deepening pass (2026-05-14) — full §5.5 contract depth. Pattern peers: symptom.vertigo.v1 (04bf795f) + symptom.dementia.v1 (1999b2d0). Engine scope: triage + risk-stratified workup + disposition for hematuria across home, ED, ICU, inpatient, outpatient. Downstream confirmed glomerular pattern routes to renal.rpgn.core.v1 (verified in ALL_DOSSIERS). Modern view (2026-05-14): AUA 2020 microhematuria CPG (Barocas PMID 32698717) codifies 3-tier risk stratification (low/intermediate/high) driving differential imaging + cystoscopy. Anticoag does NOT exclude urothelial malignancy. Schistosoma haematobium endemic-region exposure remains a high-yield phenotype (Prakash Kidney Int 2015 PMID 26126106). 5 setting playbooks (home, ed, icu, inpatient, outpatient). 12 severity triggers (≥6 per spec): gross_hematuria + microscopic_high_risk + microscopic_intermediate_risk + microscopic_low_risk + glomerular_pattern + obstructing_stone_sepsis + clot_retention + bph_associated + anticoagulant_associated + schistosomiasis_endemic + pediatric_phenotype + cyclophosphamide_hemorrhagic_cystitis. 2 sibling differentiation rows (renal.rpgn.core.v1 + uro.testicular-torsion.v1) — both verified to exist in ALL_DOSSIERS registry. Additional look-alikes (urethritis, prostatitis, vulvovaginal bleeding, factitious) captured as DIFFERENTIAL phase pivots; no dedicated dossiers yet. Bayesian linkage (LR+, LR−, T_treat, T_test, conditional dependencies, pre-test priors by setting) lives in companion depth bundle _briefs/symptom.hematuria.v1.depth.md — schema has no first-class likelihood-ratio field. Schema-blocked items surfaced: AUA microhematuria risk classifier (3-tier), RBC dysmorphism quantitation, ePLND nomograms — none in clinical-tools-registry.ts; cross-shard tickets emitted to shard-0 (registry maintainer). PMIDs (8), all PubMed-verified 2026-05-30: AUA Microhematuria 2020 (32698717) + 2025 update (40013563), IDSA UTI 2010 (21292654), KDIGO Glomerular 2021 (34556256), terminal hematuria/schistosomiasis (26126106), AUA Stones 2026 (41263322), Pathan renal colic Eur Urol 2018 (29174580), Cochrane 2025 NSAIDs renal colic (40084512). Replaced 5 fabricated PMIDs (32702087, 34556257, 19097998, 24268708, 29462017).

Entry points (6)

  • symptom
    Visible (gross) hematuria — STAT cystoscopy + CTU indication regardless of age (AUA 2020 PMID 32698717)
    gross_hematuria
  • lab_abnormality
    Microhematuria (≥3 RBC/HPF on properly collected sample) — AUA 2020 risk-stratified workup
    microhematuria_on_ua
  • symptom
    Hematuria with flank pain / dysuria — stone vs UTI vs pyelonephritis (AUA Stones 2026)
    painful_hematuria
  • symptom
    Gross hematuria with bladder clot retention — STAT CBI + urology (AUA 2020)
    hematuria_with_clot_retention
  • symptom
    Hematuria + RBC casts + proteinuria + HTN ± AKI — nephrology / RPGN route (KDIGO 2021 PMID 34556256)
    hematuria_with_nephritic_pattern
  • history
    Hematuria after travel to S. haematobium-endemic region (Prakash Kidney Int 2015 PMID 26126106)
    schistosomiasis_endemic_exposure

Required inputs (28)

  • agerequired
    demographic • used at CONTEXT
    Age >60 + smoking heavily upweights AUA 2020 high-risk tier and bladder/upper-tract Ca prior (AUA 2020 PMID 32698717)
  • sexrequired
    demographic • used at CONTEXT
    AUA 2020 low-risk thresholds differ by sex (women <50 / men <40); women — menstrual / GU bleeding confounders (AUA 2020)
  • smoking_historyrequired
    history • used at CONTEXT
    Bladder Ca risk; ≥30 pack-years → AUA 2020 high-risk regardless of age (PMID 32698717)
  • occupational_dye_exposurerequired
    history • used at CONTEXT
    Aromatic amines (rubber, leather, dye, painting, hairdressing) → urothelial Ca; AUA 2020 high-risk factor
  • gross_vs_microscopicrequired
    history • used at FRAME
    Gross hematuria at any age = AUA 2020 high-risk (5× malignancy risk over micro); STAT cysto + CTU
  • timing_in_stream
    history • used at FRAME
    Initial = urethral; terminal = bladder neck / prostate; throughout = upper tract or bladder body (AUA 2020)
  • clots_present
    history • used at FRAME
    Visible clots → non-glomerular source (clots cannot pass through glomerular filter); often heralds tumor or stone (AUA 2020)
  • recent_utis_instrumentationrequired
    history • used at CONTEXT
    Transient cause (UTI, catheter, cystoscopy, sex); reassess after treatment, but persistent micro after UTI Rx still needs AUA workup (IDSA 2010 PMID 21292654)
  • family_history_urothelial_lynch
    history • used at CONTEXT
    Lynch syndrome (HNPCC) → upper-tract urothelial; AUA 2020 high-risk factor
  • prior_pelvic_radiation_or_cyclophosphamide
    history • used at CONTEXT
    Pelvic XRT and cyclophosphamide / ifosfamide → hemorrhagic cystitis + secondary urothelial Ca; AUA 2020 high-risk
  • schistosomiasis_endemic_exposure
    history • used at CONTEXT
    S. haematobium → terminal hematuria + bladder SCC risk in endemic-region travellers (Prakash Kidney Int 2015 PMID 26126106)
  • current_medsrequired
    medication • used at CONTEXT
    Anticoag / antiplatelet, cyclophosphamide (hemorrhagic cystitis), aristolochic herb, NSAIDs (papillary necrosis), rifampin / phenazopyridine (pigmenturia mimic) (AUA 2020)
  • flank_pain_or_dysuriarequired
    symptom • used at CONTEXT
    Stone vs UTI vs pyelonephritis differential (AUA Stones 2026 PMID 41263322)
  • urinary_retention_or_lower_tract_symptoms
    symptom • used at CONTEXT
    BPH / clot retention / bladder mass; LUTS in older men shifts toward BPH-associated or bladder Ca (AUA 2020)
  • fever_or_sepsis_featuresrequired
    symptom • used at RED_FLAGS
    Obstructing stone + sepsis = urologic emergency — STAT decompression (PCN / stent); AUA Stones 2026
  • sbprequired
    vital • used at CONTEXT
    Hemodynamic instability from gross hematuria + clot retention; HTN co-traveller of glomerular pattern (KDIGO 2021)
  • hrrequired
    vital • used at CONTEXT
    Hemodynamic instability marker; sepsis criteria with obstructing stone (AUA Stones 2026)
  • ua_with_microscopyrequired
    lab • used at INITIAL_WORKUP
    Confirm true RBCs vs pigmenturia (myoglobin, hemoglobin, beet, rifampin, phenazopyridine); dysmorphic RBCs + RBC casts = glomerular (KDIGO 2021); ≥3 RBC/HPF = micro per AUA 2020
  • urine_culturerequired
    lab • used at INITIAL_WORKUP
    UTI is most common reversible cause of micro hematuria; IDSA 2010 (PMID 21292654)
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    Glomerular pattern + rising Cr → RPGN suspicion; route to renal.rpgn.core.v1 (KDIGO 2021 PMID 34556256)
  • urine_protein_creatinine_ratiorequired
    lab • used at INITIAL_WORKUP
    Proteinuria + hematuria = glomerular (KDIGO 2021); UPCR >0.5 g/g raises RPGN prior
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Hgb trend in significant gross bleeding; thrombocytopenia could amplify (AUA 2020)
  • inr_if_anticoag
    lab • used at INITIAL_WORKUP
    Anticoag-associated bleeding amplification; INR does NOT exclude tumor (AUA 2020)
  • urine_cytology
    lab • used at INITIAL_WORKUP
    High-risk per AUA 2020 — adjunct; insensitive for low-grade Ca; not routine in low-risk
  • renal_ultrasound
    imaging • used at BRANCHING_WORKUP
    Stone, mass, hydronephrosis; AUA 2020 preferred for intermediate-risk (cysto + renal US)
  • ct_urography
    imaging • used at BRANCHING_WORKUP
    AUA 2020 — preferred upper-tract imaging for high-risk (cysto + CTU); use MR urography if contrast contraindicated
  • ct_kub_non_contrast
    imaging • used at BRANCHING_WORKUP
    AUA Stones 2026 first-line for suspected ureteral stone with flank pain (PMID 41263322)
  • cystoscopy
    imaging • used at BRANCHING_WORKUP
    Required for intermediate / high-risk per AUA 2020; gold standard for bladder lesion detection

12-phase flow (12)

  1. 1FRAME
    Confirm true RBCs by microscopy — rule out pigmenturia (myoglobin, hemoglobin, beets, rifampin, phenazopyridine); classify gross vs microscopic (≥3 RBC/HPF AUA 2020); timing in stream (PMID 32698717)
    inputs: ua_with_microscopy, gross_vs_microscopic
    advance: True hematuria confirmed and gross vs micro classified
  2. 2ENTRY
    Gross hematuria, microhematuria on screening UA, painful hematuria with flank pain, hematuria with clot retention, nephritic pattern, schistosomiasis exposure (AUA 2020 + AUA Stones 2026 + KDIGO 2021)
    inputs: age
    advance: Entry pattern recognized
  3. 3CONTEXT
    Age, sex, smoking pack-years, occupational dye, gross vs micro, timing in stream, clots, pain, recent UTI / instrumentation, anticoag, family history urothelial / Lynch, prior pelvic XRT / cyclophosphamide, schistosomiasis exposure (AUA 2020 PMID 32698717)
    inputs: smoking_history, occupational_dye_exposure, recent_utis_instrumentation, current_meds, flank_pain_or_dysuria, sex, sbp, hr
    advance: Context complete with all AUA 2020 risk factors collected
  4. 4RED_FLAGS
    Gross hematuria with clots + hemodynamic compromise / clot retention; obstructing stone + sepsis / AKI; nephritic syndrome with RPGN features; trauma with gross hematuria (AUA 2020 + AUA Stones 2026 + KDIGO 2021)
    inputs: fever_or_sepsis_features
    actions: workup.nephrolithiasis, workup.rpgn
    advance: Acute red flags addressed with disposition assigned
  5. 5INITIAL_WORKUP
    UA with microscopy (dysmorphic RBCs + RBC casts = glomerular → route renal.rpgn.core.v1); urine culture; CBC; BMP / eGFR; UPCR; INR if anticoag; urine cytology in high-risk (AUA 2020 + KDIGO 2021)
    inputs: ua_with_microscopy, urine_culture, creatinine_egfr, urine_protein_creatinine_ratio, cbc
    actions: panel.ua, panel.renal, workup.hematuria
    advance: Stage-1 returned + glomerular vs non-glomerular pivot determined
  6. 6BRANCHING_WORKUP
    AUA 2020 risk-stratified pathway: low (women <50 OR men <40, never-smoker, no RFs) → repeat UA at 6 mo OR cysto + renal US shared decision; intermediate (50-60 women / 40-60 men, ≤10 pack-years, ≤25 RBC/HPF) → cysto + renal US; high (>60 yo OR >30 pack-years OR gross OR >25 RBC/HPF OR risk-factor cluster) → cysto + CT urography; glomerular pattern → nephrology biopsy decision (KDIGO 2021)
    inputs: renal_ultrasound, ct_urography, cystoscopy
    advance: Risk-tier appropriate imaging + cystoscopy or nephrology referral completed
  7. 7DIFFERENTIAL
    UTI / urolithiasis / urothelial Ca (bladder + upper-tract) / RCC / glomerulonephritis (IgA, post-infectious, lupus nephritis, RPGN, Alport, thin-BM) / BPH / endometriosis (catamenial) / exercise-induced / drug (cyclophosphamide hemorrhagic cystitis) / schistosomiasis (Prakash 2015 PMID 26126106) / trauma / sickle trait
    advance: Differential narrowed with pre-test priors documented
  8. 8RISK_STRATIFICATION
    AUA 2020 microhematuria 3-tier classifier — variables: age, sex, smoking pack-years, RBC/HPF, gross vs micro, risk-factor cluster (dye, FH urothelial / Lynch, prior pelvic XRT, cyclophosphamide, aristolochic herb, prior cytology); output: low/intermediate/high → workup pathway (PMID 32698717)
    inputs: age, smoking_history, sex
    advance: AUA tier assigned + pathway selected
  9. 9TREATMENT
    UTI → directed antibiotic (IDSA 2010 PMID 21292654); stone → MET + analgesia ± urology decompression (AUA Stones 2026); tumor → urology TURBT / nephroureterectomy; glomerular → nephrology + biopsy + immunosuppression per KDIGO 2021; cyclophosphamide → mesna + hydration; schistosomiasis → praziquantel (Prakash 2015)
    advance: Diagnosis-directed plan documented
  10. 10DISPOSITION
    Outpatient stepwise per AUA risk tier; ED for gross + clot retention / instability; admit for obstructing stone with infection, CBI failure, gross transfusion requirement; ICU for sepsis from obstructing stone + AKI (AUA 2020 + AUA Stones 2026)
    advance: Disposition documented
  11. 11MONITORING
    Repeat UA after UTI treatment to confirm clearance (IDSA 2010); 6-mo follow-up UA in AUA low-risk patients; surveillance cystoscopy q3-6 mo per urology if NMIBC; serial UPCR + Cr for glomerular (KDIGO 2021)
    advance: Monitoring plan documented
  12. 12FOLLOWUP
    Urology referral for non-glomerular per AUA tier; nephrology + biopsy decision for glomerular (KDIGO 2021); smoking cessation counseling (AUA 2020); travel-medicine for schistosomiasis post-treatment serology (Prakash 2015)
    advance: Referrals scheduled