Executive summary (what to do today)
Haematuria is a symptom, not a diagnosis. The priority in primary care is to (1) identify emergencies, (2) exclude common reversible causes (UTI, stones, anticoagulation-related bleeding that still needs workup), and (3) use NICE NG12 thresholds for suspected cancer referral.
- Visible haematuria (any frank blood) is higher-risk than isolated non-visible haematuria.
- Never attribute haematuria solely to anticoagulants — anticoagulation can unmask pathology; the work-up is usually the same.
- Always safety-net: persistent/recurrent haematuria, systemic symptoms, flank pain, anaemia, weight loss, or a palpable mass need escalation.
History + exam (red flags and common mimics)
- Confirm it is urinary: menstruation/spotting, rectal bleeding, beetroot, rifampicin, phenazopyridine, myoglobin (rhabdo).
- Symptoms: dysuria, frequency/urgency, loin pain, colicky pain (stones), fever/rigors (pyelo), LUTS, clot retention, trauma.
- Risk factors: smoking, occupational exposure, pelvic irradiation, cyclophosphamide, recurrent UTIs, analgesic nephropathy, family history, schistosomiasis travel.
- Examination: vitals, abdominal/flank tenderness, palpable bladder, genital exam (esp. men with scrotal/penile lesions), BP, signs of fluid overload/vasculitis.
Emergency features: haemodynamic instability, sepsis, clot retention (suprapubic pain + inability to pass urine), suspected obstructing stone with infection, or severe anaemia/syncope → same-day ED.
Investigations in primary care (minimum practical set)
- Urine: dipstick (blood, protein, nitrite/leukocytes), send MSU if UTI symptoms, consider microscopy if persistent non-visible haematuria.
- Bloods: FBC (anaemia), U&E/eGFR, CRP if infection suspected.
- Proteinuric/renal pattern: check ACR (or PCR), BP, and consider glomerular causes if proteinuria, casts, or declining eGFR.
- Imaging: do not delay referral if NG12 criteria met; imaging (e.g., renal US) is often arranged via urology pathways.
UTI scenario: treat per local antimicrobial guidance, then re-check if haematuria persists or recurs after treatment.
Referral thresholds (NICE NG12 – practical trigger list)
- 2-week-wait urology: aged ≥45 with unexplained visible haematuria without UTI, or visible haematuria that persists/recurs after UTI treatment.
- 2-week-wait urology: aged ≥60 with non-visible haematuria and either dysuria or raised WCC.
- Nephrology/renal referral (often routine/urgent depending on severity): haematuria with significant proteinuria, declining eGFR, uncontrolled hypertension, or systemic features (e.g., vasculitis).
Safety-net wording: if haematuria recurs, if new clots/retention occurs, if fever/rigors develop, or if weight loss/night sweats/anaemia appear → urgent review.