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Non-visible haematuria meeting suspected bladder cancer pathway referral criteria — MSRA MCQ

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HardHematuriaNon-visible haematuria meeting suspected bladder cancer pathway referral criteriaMSRA

A 61-year-old man has had two urine dipstick tests showing 2+ blood during assessment of fatigue. He has never noticed visible haematuria and has no dysuria, frequency, urgency, loin pain, fever or weight loss. Microscopy of two correctly collected midstream urine samples confirms haematuria. Both urine cultures show no significant growth. He is normotensive, with eGFR 78 mL/min/1.73 m² and urine ACR 1.4 mg/mmol. Full blood count shows a white cell count of 12.6 × 10⁹/L, confirmed as 12.2 × 10⁹/L on repeat testing 2 weeks later. What is the most appropriate next step?

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

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

This patient meets the NICE NG12 criterion for a suspected cancer pathway referral for bladder cancer: he is aged 60 years or over and has unexplained non-visible haematuria with a raised white cell count on blood testing. The haematuria is confirmed on microscopy, while two negative cultures and the absence of urinary symptoms make urinary infection an unconvincing explanation. Dysuria is not required because raised white cell count is an alternative qualifying feature. A is inappropriate because the referral threshold has already been met; further interval testing would delay the indicated pathway. C reflects a separate NICE recommendation: non-urgent referral may be considered in people aged 60 years or over with recurrent or persistent unexplained urinary tract infection. This man has no recurrent or persistent UTI and instead fulfils the higher-priority suspected cancer criterion. D may be part of subsequent specialist investigation, but primary-care imaging should not replace the required suspected cancer pathway referral. E is initially plausible in persistent non-visible haematuria, but there is no albuminuria, reduced eGFR or hypertension to prioritise renal parenchymal disease, and the specific NICE bladder-cancer referral criterion is present.

Reference: NICE NG12: Suspected cancer: recognition and referral — Bladder cancer, recommendations 1.6.4 and 1.6.5 (2015; current NICE page checked 15 August 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 and raised white cell count (2015; current NICE page checked 15 August 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommended-actions-organised-by-symptom-and-findings-of-primary-care-investigations