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Unexplained non-visible haematuria — MSRA MCQ

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HardMicrohematuriaUnexplained non-visible haematuriaMSRA

A 68-year-old man attends after two routine urine dipsticks, 3 weeks apart, each showed 1+ blood. He has not seen blood in his urine. Both samples were collected away from vigorous exercise and there is no recent urinary instrumentation. Urine microscopy confirms red cells and two midstream urine cultures show no significant growth. He has no dysuria, fever, loin pain or lower urinary tract symptoms. He takes rivaroxaban for atrial fibrillation. He stopped smoking 12 years ago (35 pack-years). Blood pressure is 132/78 mmHg, eGFR is 64 mL/min/1.73 m², urine ACR is 1.8 mg/mmol and full blood count shows a white cell count of 13.1 × 10⁹/L with neutrophilia. He is otherwise well, with no clinical focus of infection. What is the most appropriate next step?

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

Reveal the answer and explanation

Correct answer: A — Refer using a suspected cancer pathway for assessment of bladder cancer

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

This man requires a suspected cancer pathway referral for bladder cancer. He is aged 60 years or over and has unexplained non-visible haematuria with a raised peripheral white cell count. NICE NG12 specifies this combination as an indication for suspected cancer pathway referral. The haematuria has been confirmed on repeat testing and microscopy, cultures are negative, and there is no alternative infective explanation. A is inappropriate because the NICE referral threshold is already met; repeating tests would delay indicated assessment. B is not the priority: normal blood pressure, preserved eGFR, low ACR and no reported glomerular features make intrinsic renal disease less likely, whereas the cancer referral criterion is fulfilled. C is inappropriate because anticoagulation may exacerbate bleeding but does not establish its cause or remove the need to investigate qualifying haematuria; interruption also exposes him to avoidable thromboembolic risk. D is inappropriate because there are no urinary symptoms, systemic infective features or positive cultures to support UTI, and empirical antibiotics would risk delaying diagnosis.

Reference: NICE NG12: Suspected cancer: recognition and referral — Recommended actions organised by symptom and findings of primary care investigations (Updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommended-actions-organised-by-symptom-and-findings-of-primary-care-investigations Right Decisions: Haematuria — non-visible (Reviewed 11 February 2026) — https://www.rightdecisions.scot.nhs.uk/dgrefhelp-nhs-dumfries-galloway/urology/haematuria-non-visible/