Clinical Commander

Back to dossier
symptom.hematuria.v1PRODUCTION
symptom.hematuria.v1

Hematuria (gross / microscopic)

symptomacutesubacuteundifferentiatedadult
Hard-required inputs
0 / 16
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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
2
Actions
0
Advance rule
Set
Advance when

True hematuria confirmed and gross vs micro classified

Patient inputs (28)

Age >60 + smoking heavily upweights AUA 2020 high-risk tier and bladder/upper-tract Ca prior (AUA 2020 PMID 32698717)

AUA 2020 low-risk thresholds differ by sex (women <50 / men <40); women — menstrual / GU bleeding confounders (AUA 2020)

Bladder Ca risk; ≥30 pack-years → AUA 2020 high-risk regardless of age (PMID 32698717)

Aromatic amines (rubber, leather, dye, painting, hairdressing) → urothelial Ca; AUA 2020 high-risk factor

Transient cause (UTI, catheter, cystoscopy, sex); reassess after treatment, but persistent micro after UTI Rx still needs AUA workup (IDSA 2010 PMID 21292654)

Anticoag / antiplatelet, cyclophosphamide (hemorrhagic cystitis), aristolochic herb, NSAIDs (papillary necrosis), rifampin / phenazopyridine (pigmenturia mimic) (AUA 2020)

Stone vs UTI vs pyelonephritis differential (AUA Stones 2026 PMID 41263322)

Hemodynamic instability from gross hematuria + clot retention; HTN co-traveller of glomerular pattern (KDIGO 2021)

Hemodynamic instability marker; sepsis criteria with obstructing stone (AUA Stones 2026)

Gross hematuria at any age = AUA 2020 high-risk (5× malignancy risk over micro); STAT cysto + CTU

Confirm true RBCs vs pigmenturia (myoglobin, hemoglobin, beet, rifampin, phenazopyridine); dysmorphic RBCs + RBC casts = glomerular (KDIGO 2021); ≥3 RBC/HPF = micro per AUA 2020

UTI is most common reversible cause of micro hematuria; IDSA 2010 (PMID 21292654)

Glomerular pattern + rising Cr → RPGN suspicion; route to renal.rpgn.core.v1 (KDIGO 2021 PMID 34556256)

Proteinuria + hematuria = glomerular (KDIGO 2021); UPCR >0.5 g/g raises RPGN prior

Hgb trend in significant gross bleeding; thrombocytopenia could amplify (AUA 2020)

Obstructing stone + sepsis = urologic emergency — STAT decompression (PCN / stent); AUA Stones 2026

Stone, mass, hydronephrosis; AUA 2020 preferred for intermediate-risk (cysto + renal US)

AUA 2020 — preferred upper-tract imaging for high-risk (cysto + CTU); use MR urography if contrast contraindicated

AUA Stones 2026 first-line for suspected ureteral stone with flank pain (PMID 41263322)

Required for intermediate / high-risk per AUA 2020; gold standard for bladder lesion detection

Lynch syndrome (HNPCC) → upper-tract urothelial; AUA 2020 high-risk factor

Pelvic XRT and cyclophosphamide / ifosfamide → hemorrhagic cystitis + secondary urothelial Ca; AUA 2020 high-risk

S. haematobium → terminal hematuria + bladder SCC risk in endemic-region travellers (Prakash Kidney Int 2015 PMID 26126106)

BPH / clot retention / bladder mass; LUTS in older men shifts toward BPH-associated or bladder Ca (AUA 2020)

Initial = urethral; terminal = bladder neck / prostate; throughout = upper tract or bladder body (AUA 2020)

Visible clots → non-glomerular source (clots cannot pass through glomerular filter); often heralds tumor or stone (AUA 2020)

Anticoag-associated bleeding amplification; INR does NOT exclude tumor (AUA 2020)

High-risk per AUA 2020 — adjunct; insensitive for low-grade Ca; not routine in low-risk

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (12)

12 need judgement
  • informationallife_threateningobstructing_stone_sepsis
    Obstructing ureteral stone + UTI / sepsis features (fever + WBC + lactate + hypotension) — urologic emergency
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveregross_hematuria
    Visible (gross) hematuria — at any age = AUA 2020 high-risk (5× malignancy risk vs micro); STAT cystoscopy + CT urography indication (PMID 32698717)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremicroscopic_high_risk
    AUA 2020 high-risk microhematuria: age >60 OR >30 pack-years OR >25 RBC/HPF OR risk-factor cluster (FH urothelial / Lynch, dye exposure, prior pelvic XRT, cyclophosphamide, aristolochic herb)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereglomerular_pattern
    Dysmorphic RBCs + RBC casts + proteinuria (UPCR >0.5 g/g) + HTN ± rising Cr — glomerular hematuria pattern
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereclot_retention
    Gross hematuria with bladder clot retention — inability to urinate, suprapubic pain, palpable / scanned bladder distension
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecyclophosphamide_hemorrhagic_cystitis
    Hematuria during or after cyclophosphamide / ifosfamide therapy — acrolein-mediated mucosal injury; also pelvic radiation cystitis
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatemicroscopic_intermediate_risk
    AUA 2020 intermediate-risk microhematuria: women 50-60 / men 40-60 with ≤10 pack-years and ≤25 RBC/HPF and no high-risk factors
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateanticoagulant_associated
    New hematuria in patient on anticoagulant / antiplatelet — AC may amplify but does NOT exclude urothelial malignancy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateschistosomiasis_endemic
    Hematuria after travel / residence in S. haematobium-endemic region (sub-Saharan Africa, Middle East) — terminal hematuria classic
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepediatric_phenotype
    Pediatric hematuria — different prior set: post-streptococcal GN, IgA nephropathy, Alport syndrome, hypercalciuria, sickle cell trait, Wilms tumor, UTI
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildmicroscopic_low_risk
    AUA 2020 low-risk microhematuria: women <50 / men <40, never-smoker, no occupational / family / iatrogenic risk factors, RBC/HPF ≤25
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildbph_associated
    Men >50 with LUTS (frequency, urgency, weak stream, nocturia) on BPH meds with micro hematuria — diagnosis of exclusion after full AUA workup negative for tumor
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

INITIAL_WORKUPoptionalDrives risk stratification
Loading…

Recommended regimen

UTI-directed antibiotics for cystitis / pyelonephritis (IDSA 2010 PMID 21292654)
axis: hematuria_uti_directed
Selected axis "UTI-directed antibiotics for cystitis / pyelonephritis (IDSA 2010 PMID 21292654)" by default fallback (first axis)
  • nitrofurantoin
    first line
    nitrofuran
    100 mg • PO • BID × 5 d
    triggers: uncomplicated_cystitis, CrCl_ge_30
    IDSA 2010 PMID 21292654 — first-line uncomplicated cystitis; avoid pyelo / male prostatitis; AUC efficacy excellent at CrCl ≥30
    rxcui 7454
  • fosfomycin
    first line
    phosphonic_acid
    3 g • PO • single dose
    triggers: uncomplicated_cystitis
    IDSA 2010 single-dose option; lower efficacy than 5-d nitrofurantoin in some studies but excellent for resistant Enterobacterales
    rxcui 4550
  • cefpodoxime
    first line
    3rd_gen_cephalosporin
    100-200 mg • PO • BID × 7 d
    triggers: outpatient_pyelonephritis
    IDSA 2010 outpatient pyelonephritis option; check local Enterobacterales resistance
    rxcui 20489
  • ceftriaxone
    first line
    3rd_gen_cephalosporin
    1 g IV • IV • daily
    triggers: inpatient_pyelonephritis, sepsis, obstructing_stone_with_infection
    IDSA 2010 inpatient pyelo; broad Enterobacterales coverage; pair with decompression for obstructed infected stone (AUA Stones 2026)
    rxcui 2193

outpatient playbook — drug actions (5)

  1. 1. nitrofurantoin or fosfomycin
    per axis • PO • BID × 5 d / single dose
    trigger: Confirmed uncomplicated UTI on culture
    IDSA 2010 PMID 21292654
  2. 2. tamsulosin + NSAID
    0.4 mg + ketorolac 10 mg • PO • daily / q6h short course
    trigger: Distal ureteral stone ≤10 mm — MET
    AUA Stones 2026 PMID 41263322
  3. 3. lisinopril or losartan
    10 mg / 50 mg • PO • daily
    trigger: Proteinuric glomerular hematuria pending nephrology referral
    KDIGO 2021 — ACEi/ARB for proteinuric CKD; renoprotective
  4. 4. finasteride
    5 mg • PO • daily
    trigger: Confirmed BPH-associated hematuria after AUA workup negative for tumor
    AUA BPH — reduces hematuria recurrence in BPH; takes 3-6 mo
  5. 5. praziquantel
    40 mg/kg PO single dose • PO • single dose
    trigger: Confirmed S. haematobium
    Prakash Kidney Int 2015 PMID 26126106

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Visible (gross) hematuria — STAT cystoscopy + CTU indication regardless of age (AUA 2020 PMID 32698717); Microhematuria (≥3 RBC/HPF on properly collected sample) — AUA 2020 risk-stratified workup; Hematuria with flank pain / dysuria — stone vs UTI vs pyelonephritis (AUA Stones 2026).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Hematuria (gross / microscopic)** (symptom.hematuria.v1).
Phenotype framing: 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
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **UTI-directed antibiotics for cystitis / pyelonephritis (IDSA 2010 PMID 21292654)**.
1. nitrofurantoin 100 mg PO BID × 5 d (nitrofuran, first line) — IDSA 2010 PMID 21292654 — first-line uncomplicated cystitis; avoid pyelo / male prostatitis; AUC efficacy excellent at CrCl ≥30
2. fosfomycin 3 g PO single dose (phosphonic_acid, first line) — IDSA 2010 single-dose option; lower efficacy than 5-d nitrofurantoin in some studies but excellent for resistant Enterobacterales
3. cefpodoxime 100-200 mg PO BID × 7 d (3rd_gen_cephalosporin, first line) — IDSA 2010 outpatient pyelonephritis option; check local Enterobacterales resistance
4. ceftriaxone 1 g IV IV daily (3rd_gen_cephalosporin, first line) — IDSA 2010 inpatient pyelo; broad Enterobacterales coverage; pair with decompression for obstructed infected stone (AUA Stones 2026)

Setting playbook (outpatient) — AUA 2020 risk-stratified pathway: low → 6-mo repeat UA OR shared cysto + renal US; intermediate → cysto + renal US; high → cysto + CTU; nephrology + biopsy decision if glomerular; urology for non-glomerular; long-term BPH / Meniere-equivalent for known phenotypes (AUA 2020 + KDIGO 2021)
5. nitrofurantoin or fosfomycin per axis PO BID × 5 d / single dose — Confirmed uncomplicated UTI on culture (IDSA 2010 PMID 21292654)
6. tamsulosin + NSAID 0.4 mg + ketorolac 10 mg PO daily / q6h short course — Distal ureteral stone ≤10 mm — MET (AUA Stones 2026 PMID 41263322)
7. lisinopril or losartan 10 mg / 50 mg PO daily — Proteinuric glomerular hematuria pending nephrology referral (KDIGO 2021 — ACEi/ARB for proteinuric CKD; renoprotective)
8. finasteride 5 mg PO daily — Confirmed BPH-associated hematuria after AUA workup negative for tumor (AUA BPH — reduces hematuria recurrence in BPH; takes 3-6 mo)
9. praziquantel 40 mg/kg PO single dose PO single dose — Confirmed S. haematobium (Prakash Kidney Int 2015 PMID 26126106)

Non-pharmacologic actions:
- Refer urology per AUA tier (intermediate → cysto + renal US; high → cysto + CTU)
- Refer nephrology if glomerular pattern (KDIGO 2021)
- Smoking cessation counseling — AUA 2020 strong recommendation
- Occupational exposure mitigation if dye worker
- Schistosomiasis serology + ova clearance follow-up
- Genetic counseling if Lynch suspicion

AVOID / contraindication checks:
- Nitrofurantoin_block_if_CrCl_lt_30
- Nitrofurantoin_pulmonary_fibrosis_if_chronic
- Fluoroquinolone_avoid_outpatient_first_line_FDA_warning_2016
- Cephalosporin_anaphylaxis_history

Monitoring

Regimen monitoring:
- symptom resolution at 72h
- repeat UA after treatment for microhematuria persistence per AUA 2020
- urine culture clearance if pyelonephritis

Setting (outpatient) monitoring:
- Repeat UA after UTI treatment to confirm clearance
- AUA low-risk: repeat UA at 6 mo
- AUA intermediate-risk after negative workup: repeat UA at 12 mo and shared decision re-imaging
- AUA high-risk after negative workup: repeat UA + cytology in 12 mo
- Glomerular: serial UPCR + Cr q3-6 mo (KDIGO 2021)
- Post-TURBT: surveillance cysto q3-6 mo for NMIBC (AUA Bladder Cancer)

Follow-up plan: 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)
- Close-out criterion: Referrals scheduled

Monitoring phase: 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)

Disposition

Current setting: outpatient — AUA 2020 risk-stratified pathway: low → 6-mo repeat UA OR shared cysto + renal US; intermediate → cysto + renal US; high → cysto + CTU; nephrology + biopsy decision if glomerular; urology for non-glomerular; long-term BPH / Meniere-equivalent for known phenotypes (AUA 2020 + KDIGO 2021)

Disposition criteria:
- Continue outpatient if stable + workup compliant
- Refer urology / nephrology per AUA pathway
- Surveillance per urology if tumor diagnosed

Escalation triggers (move to higher acuity):
- New gross hematuria → urgent urology / ED
- Persistent micro hematuria after low-risk 6-mo UA → upgrade workup to intermediate-risk pathway
- Rising Cr / new proteinuria → nephrology urgently — RPGN consideration (renal.rpgn.core.v1)
- Symptomatic anemia → CBC + urology

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Obstructing ureteral stone + UTI / sepsis features (fever + WBC + lactate + hypotension) — urologic emergency
- [SEVERE] Visible (gross) hematuria — at any age = AUA 2020 high-risk (5× malignancy risk vs micro); STAT cystoscopy + CT urography indication (PMID 32698717)
- [SEVERE] AUA 2020 high-risk microhematuria: age >60 OR >30 pack-years OR >25 RBC/HPF OR risk-factor cluster (FH urothelial / Lynch, dye exposure, prior pelvic XRT, cyclophosphamide, aristolochic herb)

Citations

- AUA/SUFU Microhematuria Guideline 2020 + 2025 update (Barocas) + IDSA/ESCMID Uncomplicated UTI 2010 (Gupta) + AUA Surgical Management of Stones Guideline 2026 (Pearle) + KDIGO 2021 Glomerular Diseases + urogenital schistosomiasis (Prakash, Kidney Int 2015) [PMID:32698717](https://pubmed.ncbi.nlm.nih.gov/32698717/)
- Cited evidence (PMID 40013563) [PMID:40013563](https://pubmed.ncbi.nlm.nih.gov/40013563/)
- Cited evidence (PMID 21292654) [PMID:21292654](https://pubmed.ncbi.nlm.nih.gov/21292654/)
- Cited evidence (PMID 34556256) [PMID:34556256](https://pubmed.ncbi.nlm.nih.gov/34556256/)
- Cited evidence (PMID 26126106) [PMID:26126106](https://pubmed.ncbi.nlm.nih.gov/26126106/)

Last reconciled with current guidelines: 2026-05-30.
References
  • AUA/SUFU Microhematuria Guideline 2020 + 2025 update (Barocas) + IDSA/ESCMID Uncomplicated UTI 2010 (Gupta) + AUA Surgical Management of Stones Guideline 2026 (Pearle) + KDIGO 2021 Glomerular Diseases + urogenital schistosomiasis (Prakash, Kidney Int 2015) — PMID:32698717
  • Cited evidence (PMID 40013563) — PMID:40013563
  • Cited evidence (PMID 21292654) — PMID:21292654
  • Cited evidence (PMID 34556256) — PMID:34556256
  • Cited evidence (PMID 26126106) — PMID:26126106