In a patient with microscopic hematuria requiring DOT clearance, should the repeat clean‑catch urine sample and microscopic urinalysis be ordered by the primary‑care physician, with definitive imaging and cystoscopy performed by a board‑certified urologist (or nephrologist) and reviewed by a DOT‑certified medical examiner?

DOT Clearance Hematuria: Who Orders What?

In a patient with microscopic hematuria requiring DOT clearance, the primary-care physician should confirm true hematuria with microscopic urinalysis (≥3 RBC/HPF), perform initial risk stratification, and then refer to a board-certified urologist for definitive imaging and cystoscopy—the DOT-certified medical examiner reviews the completed work-up but does not order diagnostic tests. 1, 2

Role of the Primary-Care Physician

• Confirm microscopic hematuria by ordering a clean-catch midstream urine specimen with microscopic analysis showing ≥3 red blood cells per high-power field (RBC/HPF) on at least two of three properly collected specimens before initiating any further work-up. 1, 2

• Do not rely on dipstick testing alone, as it has only 65–99% specificity and can produce false positives from myoglobin, hemoglobin, menstrual blood, or contaminants. 1, 2

• Exclude transient benign causes by repeating urinalysis 48 hours after cessation of vigorous exercise, menstruation, viral illness, or recent sexual activity—if hematuria resolves, no further evaluation is needed. 1, 3

• Obtain urine culture before antibiotics if infection is suspected based on urinalysis or symptoms; if infection is confirmed, repeat urinalysis 6 weeks after treatment to document resolution of hematuria. 1, 2

• Perform risk stratification using the American Urological Association criteria: assess age, smoking history (pack-years), degree of hematuria (RBC/HPF), history of gross hematuria, occupational exposure to benzenes/aromatic amines, and irritative voiding symptoms without infection. 1, 2

When to Refer to Urology

• Refer immediately to a board-certified urologist if any high-risk features are present: age ≥40 years (men) or ≥60 years (women), smoking history >30 pack-years, any prior gross hematuria (even if self-limited), occupational chemical exposure, irritative voiding symptoms without infection, or hematuria >25 RBC/HPF. 1, 2

• Gross hematuria carries a 30–40% malignancy risk and mandates urgent urologic referral within 24–48 hours, even if bleeding appears self-limited. 1, 2

• Never attribute hematuria to anticoagulation or antiplatelet therapy (warfarin, DOACs, aspirin, clopidogrel)—these medications may unmask underlying pathology but do not cause hematuria, so evaluation must proceed regardless. 1, 2

Role of the Urologist

• The urologist orders and performs cystoscopy, which is mandatory for all patients ≥40 years with microscopic hematuria or any patient with gross hematuria—flexible cystoscopy is preferred because it provides equivalent or superior diagnostic accuracy with less discomfort. 1, 2

• The urologist orders multiphasic CT urography (unenhanced, nephrographic, and excretory phases), which is the preferred imaging modality with 96% sensitivity and 99% specificity for detecting renal cell carcinoma, transitional cell carcinoma, and urolithiasis. 1, 2

• Voided urine cytology should be obtained by the urologist in high-risk patients (age >60 years, smoking >30 pack-years, occupational exposures) to detect high-grade urothelial carcinomas and carcinoma in situ. 1, 2

When to Refer to Nephrology (in Addition to Urology)

• Refer to nephrology if glomerular features are present: >80% dysmorphic RBCs on urinary sediment, red-cell casts (pathognomonic for glomerular disease), protein-to-creatinine ratio >0.5 g/g, tea- or cola-colored urine, elevated serum creatinine, or hypertension accompanying hematuria. 1, 2

• The presence of glomerular features does not eliminate the need for urologic evaluation—both evaluations should be completed because malignancy can coexist with medical renal disease. 1, 2

Role of the DOT-Certified Medical Examiner

• The DOT examiner reviews the completed urologic work-up (cystoscopy report, CT urography results, pathology if biopsies were performed) to determine medical fitness for commercial driving. 1, 2

• The DOT examiner does not order diagnostic tests—they assess whether the underlying cause of hematuria (if identified) or the absence of a serious diagnosis (if work-up is negative) meets DOT medical standards. 1, 2

• If the urologic work-up is negative, the DOT examiner may clear the driver after documenting that no serious pathology was found and that hematuria is either resolved or attributed to a benign cause. 1, 2

Common Pitfalls to Avoid

• Do not delay urologic referral while treating a presumed UTI in patients ≥40 years—age alone is sufficient justification for full work-up, and infection does not exclude concurrent malignancy. 1, 2

• Do not assume intermittent hematuria is benign—cancer-related bleeding is often intermittent, and a single positive microscopic result (≥3 RBC/HPF) is sufficient to trigger evaluation when hematuria is clinically significant. 1, 2

• Do not skip cystoscopy even if CT urography is normal—bladder cancer accounts for 30–40% of gross hematuria cases and 2.6–4% of microscopic hematuria cases, and imaging alone cannot exclude bladder pathology. 1, 2

• Do not attribute hematuria to benign prostatic hyperplasia (BPH) without completing the full work-up—BPH can cause hematuria but does not exclude concurrent malignancy, and gross hematuria from BPH must be proven to be of prostatic etiology through appropriate evaluation. 1, 2