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Recurrent visible haematuria after successfully treated urinary tract infection — MSRA MCQ

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HardHematuriaRecurrent visible haematuria after successfully treated urinary tract infectionMSRA

A 53-year-old woman takes apixaban for atrial fibrillation. She was treated 10 days ago with culture-directed antibiotics for an Escherichia coli lower urinary tract infection, which presented with dysuria, frequency and visible haematuria. Her urinary symptoms resolved fully. Five days after completing antibiotics, she has a further painless episode of visible haematuria. She is systemically well, has no loin pain or urinary retention, and a repeat midstream urine culture shows no significant growth. Her eGFR is unchanged from baseline. What is the most appropriate next step?

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Correct answer: C — Refer using a suspected cancer pathway for assessment of bladder and renal cancer

Explanation lettering: E = shown as B · D = shown as C · B = shown as D · C = shown as E

This patient requires suspected cancer pathway referral. She is over 45 years old and has visible haematuria that has recurred after successful treatment of a microbiologically confirmed UTI. Resolution of dysuria and frequency, followed by a negative repeat culture, makes ongoing infection an inadequate explanation for the recurrent haematuria. NICE recommends suspected cancer pathway referral in this situation because visible haematuria may indicate bladder or renal cancer. A is inappropriate because repeating testing delays referral once the referral criterion is met; repeat culture has already shown no significant growth. B is insufficient because a primary-care ultrasound does not replace the suspected cancer pathway assessment required for possible urothelial or renal malignancy. C is inappropriate because anticoagulation may increase the visibility of bleeding but does not remove the need to investigate recurrent post-UTI visible haematuria; interrupting apixaban also requires an individual thromboembolic-risk assessment. E selects the wrong urgency: this presentation meets criteria for a suspected cancer pathway rather than routine urology referral.

Reference: NICE NG12: Suspected cancer: recognition and referral — Recommendations organised by site of cancer (Updated 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer NICE QS215: Kidney cancer — Quality statement 1: Suspected cancer pathway referral (19 March 2026) — https://www.nice.org.uk/guidance/qs215/chapter/Quality-statement-1-Suspected-cancer-pathway-referral