Main differential diagnosis

1. Bladder / lower tract causes

• Urothelial carcinoma of the bladder, including papillary tumor and carcinoma in situ
• Prostatic urothelial cancer or bleeding from severe BPH/prostatic malignancy
• Bladder stone, catheter/instrument trauma, radiation cystitis
• Hemorrhagic or infectious cystitis
• Less commonly, bladder metastasis or lymphoma

2. Upper-tract urothelial malignancy

• Renal-pelvis or ureteric urothelial carcinoma
• May coexist with a bladder tumor, especially with smoking, occupational exposures, prior urothelial cancer, Lynch syndrome, or analgesic exposure.

3. Renal causes, including the cystic lesions

• Simple bilateral renal cysts: frequent with advanced age and usually not the source of persistent frank hematuria unless hemorrhagic/ruptured.
• Hemorrhagic renal cyst: hyperdense on non-contrast CT; may cause hematuria.
• Complex renal cyst / cystic renal cell carcinoma: particularly if enhancing septa, irregular thick wall, mural nodule, or solid component.
• Renal cell carcinoma, including cystic RCC.
• Acquired cystic kidney disease, if longstanding advanced CKD or dialysis, with increased RCC risk.
• ADPKD: usually supported by enlarged kidneys, family history, liver cysts, hypertension, and/or reduced renal function. New recognition at 88 would be less typical, but not impossible.
• Renal calculi, papillary necrosis, renal infarction, pyelonephritis.

4. Medical renal or systemic causes

• Glomerulonephritis, especially if proteinuria, dysmorphic RBCs, RBC casts, hypertension, or renal impairment
• Anticoagulant-associated bleeding or coagulopathy. Do not attribute hematuria solely to anticoagulation because it may unmask tumor.
• Thrombocytopenia, DIC, liver disease
• Pigmenturia or medication/food discoloration, although this is less likely with confirmed RBCs on microscopy.

Recommended workup

A. Immediate clinical assessment

• Hemodynamic status, urine output, degree of bleeding, clots/retention.
• Focused history:
  • Painful versus painless bleeding; initial, terminal, or total hematuria
  • Smoking history, occupational aromatic amine exposure
  • Previous urothelial cancer, pelvic radiotherapy, cyclophosphamide
  • Anticoagulants/antiplatelets and timing of last dose
  • Fever, dysuria, flank pain, stones, weight loss
  • CKD/dialysis history and family history of polycystic kidney disease or RCC.
• Examination: abdominal/flank mass, bladder distension, DRE where appropriate, lymph nodes, edema and blood pressure.

B. Essential laboratory tests

• Urinalysis with microscopy: RBC count, protein, casts, dysmorphic RBCs.
• Urine culture before antibiotics if infection is plausible.
• CBC with platelet count and serial hemoglobin if ongoing bleeding.
• Creatinine/eGFR, electrolytes, LFTs.
• PT/INR, aPTT, especially if anticoagulated or liver disease is possible.
• Group and screen/crossmatch if substantial bleeding.
• Voided urine cytology, preferably before instrumentation, because it may help identify high-grade urothelial carcinoma/CIS. A negative result does not exclude cancer.

C. Imaging

• Multiphasic CT urography, ideally planned to assess both:
  1. renal parenchyma/cystic masses, and
  2. urothelium of kidneys, ureters, and bladder.

• Characterize each renal lesion by Bosniak 2019 criteria.
• Identify enhancement, wall/septal thickness, nodules, calcification, hemorrhage, solid renal mass, collecting-system lesion, hydronephrosis, nodes, and metastases.
• Clarify whether the “bladder mass” might be clot, stone, prostate impression, diverticular lesion, or true enhancing tumor.

• MR urography plus renal-protocol MRI if feasible.
• If MRI also cannot be done, renal ultrasound plus non-contrast CT and retrograde pyelography may be used, though this is less complete for urothelial disease.

D. Definitive lower-tract investigation

• Prompt flexible cystoscopy.
• If a tumor is identified: transurethral resection of bladder tumor (TURBT) with adequate tissue including detrusor muscle when appropriate.
• Send pathology for tumor type, grade, depth of invasion, CIS/variant histology, and lymphovascular invasion.
• Examination under anesthesia may be needed for a bulky lesion.

E. If active clot retention or heavy bleeding

• Large-bore three-way urethral catheter.
• Manual clot evacuation and continuous bladder irrigation with normal saline.
• Correct significant coagulopathy in coordination with the clinician who manages anticoagulation.
• Urgent cystoscopy and clot evacuation/fulguration if bleeding continues or drainage cannot be maintained.

How I would frame the likely working diagnosis

1. Suspected bladder urothelial carcinoma causing visible hematuria, pending cystoscopy and TURBT pathology.
2. Bilateral renal cystic lesions requiring renal-protocol CT/MRI characterization, not assumed benign.
3. Screen in parallel for infection, stone disease, renal impairment, coagulopathy, and glomerular disease.

Practical referral plan

• Urgent urology referral, not routine follow-up.
• Urology should coordinate cystoscopy/TURBT and review the CT urogram.
• Add nephrology if there is CKD, substantial proteinuria, RBC casts/dysmorphic RBCs, suspected ADPKD, or acquired cystic kidney disease.
• In an 88-year-old, treatment decisions after staging should incorporate frailty, cognition, functional status, anesthesia risk, renal function, life expectancy, and the patient’s goals, but these factors should not delay establishing the diagnosis or relieving obstruction/bleeding.