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Recurrent visible haematuria after treated urinary tract infection — MSRA MCQ

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HardUrologyRecurrent visible haematuria after treated urinary tract infectionMSRA

A 62-year-old woman presents with two further episodes of painless visible haematuria over 5 days. Eight weeks earlier, she had dysuria, frequency and visible haematuria; urine culture grew Escherichia coli and symptoms resolved completely after culture-directed antibiotics. She is now afebrile, has no dysuria or loin pain, and a repeat midstream urine culture shows no significant growth. Her eGFR is 71 mL/min/1.73 m². She takes apixaban for atrial fibrillation. There is no vaginal bleeding on examination. What is the most appropriate next step?

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Correct answer: B — Refer using a suspected cancer pathway referral

This woman needs a suspected cancer pathway referral. She is over 45 and has visible haematuria that has recurred after successful treatment of a culture-confirmed UTI. Her current negative culture and absence of infective symptoms make an active UTI an inadequate explanation. NICE recommends suspected cancer pathway referral for visible haematuria in this setting because bladder and renal malignancy must be excluded. Apixaban can contribute to bleeding but should not be used to attribute away recurrent visible haematuria in a patient meeting the referral criteria; it does not remove the need to investigate for underlying urological pathology. A routine referral is insufficiently urgent. Direct-access renal and bladder ultrasound may form part of subsequent diagnostic assessment, but it should not replace the specified suspected cancer pathway referral. Repeating culture or urinalysis would delay referral despite already having a negative culture after recurrence of haematuria.

Reference: Suspected cancer: recognition and referral (NG12) — Recommendations organised by site of cancer (Updated 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer Kidney cancer (QS215) — 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