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uro.hematuria-microscopic-surveillance.v1PRODUCTION
uro.hematuria-microscopic-surveillance.v1

Microscopic Hematuria Surveillance — chronic outpatient post-workup (AUA 2020 low / intermediate / high risk bands + IgA / Alport / sickle / anticoag / pediatric / schistosomiasis overlays)

urologychronicadultpediatricgeriatric
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Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Adult / pediatric / geriatric patient with completed initial microhematuria workup per AUA 2020; entering surveillance phase (AUA 2020)

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Patient inputs (18)

Current / former smoker raises bladder cancer risk → high risk band (AUA 2020)

Aniline dye / rubber / leather / textile / cyclophosphamide exposure → high risk band (AUA 2020)

Family hx Alport / IgA / thin BM / hereditary nephritis → genetic workup

Warfarin / DOAC / antiplatelet — anticoag should NOT mask workup; rule structural lesion before attributing to anticoag

Prior AUA 2020 risk stratification (low / intermediate / high) anchors surveillance cadence

Prior cysto + imaging findings (normal vs benign vs CIS / dysplasia) drives cadence

Age >60 + smoker = high risk band; pediatric pattern differs (less malignancy, more thin BM / IgA / Alport / hypercalciuria) (AUA 2020)

Women <50 + men <40 + never-smoker is low risk (AUA 2020)

Surveillance UA — RBC count, dysmorphic RBC + RBC casts (glomerular), proteinuria (ACR), nitrites (UTI exclusion) (AUA 2020)

Baseline renal function + monitoring for glomerular phenotype progression (KDIGO 2021)

HTN + glomerular phenotype → progressive CKD risk; KDIGO 2021 target <130/80

Surveillance imaging cadence: q3-5y intermediate; baseline + per findings high risk (AUA 2020)

High-risk surveillance — annual UA + cysto q1-3y per initial path findings (AUA 2020)

Pelvic radiation raises radiation cystitis + secondary malignancy risk

First-degree relative with bladder or renal cancer → AUA 2020 risk modifier

Sickle trait → papillary necrosis / hyposthenuria; route heme.sickle-cell.core.v1

Travel / immigration from endemic area → Schistosoma haematobium screening → squamous bladder cancer risk

Proteinuria + hematuria = glomerular phenotype → route renal.iga-nephropathy.v1 OR renal.rpgn.core.v1 (KDIGO 2021)

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Severity triggers (11)

11 need judgement
  • informationalsevererecurrent_gross_re_workup
    Recurrent gross hematuria during surveillance → full re-workup (cysto + cross-sectional upper tract imaging) (AUA 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateAUA_2020_intermediate_risk_post_cysto
    AUA 2020 intermediate risk band: mild risk factors OR 11-25 RBC/HPF — annual UA + renal US/CT urography baseline then q3-5y
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateAUA_2020_high_risk_post_workup
    AUA 2020 high risk band: smoker, age >60, chemical exposure, >25 RBC/HPF, gross intermittent — annual UA + cystoscopy q1-3y per initial path findings
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateIgA_glomerular
    IgA nephropathy on prior renal biopsy OR new glomerular features (dysmorphic RBCs, RBC casts, proteinuria) — route renal.iga-nephropathy.v1 (KDIGO 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatethin_basement_membrane_Alport
    Hereditary nephritis — thin BM / Alport — family hx hematuria + hearing loss + renal failure; genetic testing (COL4A3/4/5); monitor renal function (KDIGO 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateanticoagulant_associated
    Microhematuria on warfarin / DOAC / antiplatelet — RULE structural lesion BEFORE attributing to anticoag (AUA 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateschistosomiasis_endemic_overlay
    Travel / immigration from endemic area (Africa, Middle East) → S. haematobium screening → squamous bladder cancer risk; praziquantel treatment (WHO;)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildAUA_2020_low_risk_surveillance
    AUA 2020 low risk band: women <50 / men <40, never-smoker, 3-10 RBC/HPF, no risk factors — repeat UA at 6 mo
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildpersistent_micro_negative_workup
    Persistent microhematuria after a fully negative AUA 2020 workup — reassure but maintain band-cadence surveillance (AUA 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildsickle_trait
    Sickle trait → papillary necrosis / hyposthenuria pattern; route heme.sickle-cell.core.v1 for trait-specific counseling
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildpediatric_chronic_micro
    Pediatric chronic microhematuria — less malignancy risk; consider thin BM / Alport / IgA / hypercalciuria; spot calcium-creatinine ratio (KDIGO 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

AUA 2020 microhematuria surveillance schedule + risk-factor modification
axis: microhematuria_surveillance_schedulestep 1 - Tier 1 — Low risk surveillance (women <50 / men <40, never-smoker, 3-10 RBC/HPF, no risk factors)
Selected step "Tier 1 — Low risk surveillance (women <50 / men <40, never-smoker, 3-10 RBC/HPF, no risk factors)" — AUA 2020 low risk band
  • Repeat UA at 6 months
    first line
    surveillance_schedule
    triggers: AUA_low_risk_band
    AUA Microhematuria 2020 — if positive at 6 mo, reclassify to intermediate risk

outpatient playbook — drug actions (3)

  1. 1. nicotine replacement OR varenicline OR bupropion SR
    NRT patch 21 mg / varenicline 1 mg BID / bupropion 150 mg BID • transdermal/PO • daily / BID
    trigger: Current smoker (AUA 2020)
    Smoking cessation reduces bladder cancer risk
  2. 2. lisinopril OR losartan
    Lisinopril 10 mg daily / losartan 50 mg daily • PO • daily
    trigger: HTN + CKD + glomerular phenotype (KDIGO 2021)
    ACEi/ARB reduces proteinuria + slows CKD progression
  3. 3. praziquantel
    40 mg/kg PO single dose • PO • single
    trigger: Schistosomiasis endemic exposure (WHO)
    Antihelminthic for S. haematobium

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Index AUA 2020 microhematuria workup completed (cystoscopy ± CT urography) — entering surveillance phase; Repeat UA at surveillance visit shows positive micro (3+ RBC/HPF) → reassess risk band; Recurrent gross hematuria during surveillance → full re-workup required (AUA 2020).

Objective

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

Assessment

**Microscopic Hematuria Surveillance — chronic outpatient post-workup (AUA 2020 low / intermediate / high risk bands + IgA / Alport / sickle / anticoag / pediatric / schistosomiasis overlays)** (uro.hematuria-microscopic-surveillance.v1).
Phenotype framing: Reaffirm prior workup OR identify new pathology — stone, GU malignancy, glomerular disease, hereditary nephritis (Alport / thin BM), sickle trait, anticoag-related, schistosomiasis (AUA 2020; KDIGO 2021)
Scope: Adult / pediatric / geriatric patient with completed initial microhematuria workup per AUA 2020; entering surveillance phase (AUA 2020)

No severity triggers fired against current inputs.

Plan

Regimen axis: **AUA 2020 microhematuria surveillance schedule + risk-factor modification** — step "Tier 1 — Low risk surveillance (women <50 / men <40, never-smoker, 3-10 RBC/HPF, no risk factors)".
1. Repeat UA at 6 months (surveillance_schedule, first line) — AUA Microhematuria 2020 — if positive at 6 mo, reclassify to intermediate risk

Setting playbook (outpatient) — Risk-band-cadence surveillance visits; same-day UA + BP + weight; lab draw for BMP / ACR if glomerular suspected; refer cysto / imaging per band (AUA 2020)
2. nicotine replacement OR varenicline OR bupropion SR NRT patch 21 mg / varenicline 1 mg BID / bupropion 150 mg BID transdermal/PO daily / BID — Current smoker (AUA 2020) (Smoking cessation reduces bladder cancer risk)
3. lisinopril OR losartan Lisinopril 10 mg daily / losartan 50 mg daily PO daily — HTN + CKD + glomerular phenotype (KDIGO 2021) (ACEi/ARB reduces proteinuria + slows CKD progression)
4. praziquantel 40 mg/kg PO single dose PO single — Schistosomiasis endemic exposure (WHO) (Antihelminthic for S. haematobium)

Non-pharmacologic actions:
- Surveillance schedule per AUA 2020 risk band (AUA 2020)
- Smoking cessation counseling at every visit
- Occupational exposure mitigation (AUA 2020)
- Nephrology referral if glomerular phenotype (KDIGO 2021)
- Urology referral if new positive workup findings
- Genetic counseling for Alport / thin BM / familial hematuria
- Anticoag-decision review (heme.anticoagulation-management.core.v1)
- Schistosomiasis endemic education + screening (WHO)

AVOID / contraindication checks:
- Do_not_attribute_to_anticoag_until_structural_lesion_ruled_out (AUA 2020)
- Reassess_risk_band_q5y_or_with_new_risk_factors (AUA 2020)

Monitoring

Regimen monitoring:
- UA q6mo (low risk) (AUA 2020)
- UA annual + imaging q3-5y (intermediate) (AUA 2020)
- UA annual + cysto q1-3y (high risk) (AUA 2020)
- BP at each visit
- eGFR + ACR per CKD stage (KDIGO 2021)

Setting (outpatient) monitoring:
- UA per band cadence (AUA 2020)
- BP per visit (target <130/80 CKD) (KDIGO 2021)
- eGFR + ACR per CKD stage (KDIGO 2021)
- Reassess risk band q5y or with new risk factor (AUA 2020)

Follow-up plan: Annual review; reassess risk band q5y or with new risk factors (cigarette restart, occupational exposure change, new family hx); coordinate with primary care (AUA 2020)
- Close-out criterion: follow-up scheduled

Monitoring phase: UA q6mo (low risk), annual UA + imaging q3-5y (intermediate), annual UA + cysto q1-3y (high); BP at each visit; creatinine + eGFR + ACR per CKD stage; pediatric calcium-creatinine ratio (AUA 2020; KDIGO 2021)

Disposition

Current setting: outpatient — Risk-band-cadence surveillance visits; same-day UA + BP + weight; lab draw for BMP / ACR if glomerular suspected; refer cysto / imaging per band (AUA 2020)

Disposition criteria:
- Stable surveillance findings → continue band cadence (AUA 2020)
- New findings → escalate workup OR route specialty engine
- Stable q5y → reassess risk band

Escalation triggers (move to higher acuity):
- Recurrent gross hematuria → full re-workup → route symptom.hematuria.v1 (AUA 2020)
- New RBC casts + proteinuria + declining eGFR → STAT nephrology → route renal.iga-nephropathy.v1 OR renal.rpgn.core.v1 (KDIGO 2021)
- New flank mass / weight loss / B symptoms → STAT urology + onc (AUA 2020)
- Pediatric proteinuria + HTN → STAT nephrology (KDIGO 2021)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Recurrent gross hematuria during surveillance → full re-workup (cysto + cross-sectional upper tract imaging) (AUA 2020)
- [MODERATE] AUA 2020 intermediate risk band: mild risk factors OR 11-25 RBC/HPF — annual UA + renal US/CT urography baseline then q3-5y
- [MODERATE] AUA 2020 high risk band: smoker, age >60, chemical exposure, >25 RBC/HPF, gross intermittent — annual UA + cystoscopy q1-3y per initial path findings

Citations

- Microhematuria: AUA/SUFU Guideline (Barocas DA et al, J Urol 2020 PMID 32698717) — risk-stratified (low/intermediate/high) evaluation with cystoscopy + upper-tract imaging; microhematuria defined as ≥3 RBC/HPF on a single specimen. Schistosomiasis (praziquantel) considered in endemic-exposure hematuria. [PMID:32698717](https://pubmed.ncbi.nlm.nih.gov/32698717/)

Last reconciled with current guidelines: 2026-05-22.
References
  • Microhematuria: AUA/SUFU Guideline (Barocas DA et al, J Urol 2020 PMID 32698717) — risk-stratified (low/intermediate/high) evaluation with cystoscopy + upper-tract imaging; microhematuria defined as ≥3 RBC/HPF on a single specimen. Schistosomiasis (praziquantel) considered in endemic-exposure hematuria. — PMID:32698717