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Unexplained non-visible haematuria with dysuria — MSRA MCQ

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HardHematuriaUnexplained non-visible haematuria with dysuriaMSRA

A 63-year-old woman presents with 3 weeks of dysuria and urinary frequency. She has not noticed visible haematuria. Urine dipstick testing on three occasions over 3 weeks has shown 2+ blood. Microscopy confirms red cells, with no casts. Two midstream urine cultures, taken before antibiotics, show no significant growth. She is afebrile and has no loin pain, vaginal bleeding or vaginal discharge. Blood pressure is 126/74 mmHg, eGFR is 82 mL/min/1.73 m², urine ACR is 1.1 mg/mmol and full blood count is normal, including a white cell count of 7.4 × 10⁹/L. What is the most appropriate next step?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Refer using a suspected cancer pathway for bladder cancer

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

This patient meets NICE criteria for a suspected cancer pathway referral for bladder cancer: she is aged 60 years or over and has unexplained non-visible haematuria with dysuria. A raised peripheral white cell count is an alternative qualifying feature, not an additional requirement. The repeated negative urine cultures make ongoing bacterial UTI an insufficient explanation for the haematuria and symptoms. A is inappropriate because there is no microbiological evidence of UTI and empirical treatment would delay indicated cancer-pathway assessment. B is insufficient: routine referral and pre-referral imaging should not replace the suspected cancer pathway when NG12 criteria are met. D incorrectly requires persistence beyond the information already available or a raised white cell count; neither is necessary in a patient aged 60 years or over with dysuria. E is less appropriate because there is no proteinuria, hypertension, impaired renal function or urinary casts to suggest a glomerular cause. The referral should include relevant available results, but should not be delayed to obtain further tests.

Reference: NICE NG12: Suspected cancer: recognition and referral — Recommendations organised by site of cancer, section 1.6.4 Bladder cancer (Last updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer NICE NG12: Recommended actions organised by symptom and findings of primary care investigations — Haematuria (Last updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommended-actions-organised-by-symptom-and-findings-of-primary-care-investigations