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Persistent unexplained non-visible haematuria with dysuria — MSRA MCQ

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HardMicrohematuriaPersistent unexplained non-visible haematuria with dysuriaMSRA

A 62-year-old woman is reviewed 3 weeks after treatment of a culture-confirmed Escherichia coli urinary tract infection. Her initial dysuria and frequency improved with nitrofurantoin, but she now reports persistent mild dysuria without fever, loin pain, vaginal bleeding or visible haematuria. She is postmenopausal and does not smoke. A repeat midstream urine culture shows no significant growth. Urine microscopy confirms red cells. Full blood count is normal, including white cell count. eGFR is 78 mL/min/1.73 m² and urine ACR is 1.6 mg/mmol. She has no proteinuria, hypertension, recent instrumentation or vigorous exercise. What is the most appropriate next management step?

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

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

This patient requires a suspected cancer pathway referral for bladder cancer. NICE NG12 recommends this for people aged 60 years or over with unexplained non-visible haematuria plus either dysuria or a raised white cell count. She is 62, has dysuria and microscopy-confirmed non-visible haematuria. The haematuria remains unexplained because her repeat culture is negative following successful treatment of the initial UTI. A normal white cell count does not alter the indication: dysuria alone fulfils the associated-feature criterion. A is insufficiently urgent because she meets suspected cancer pathway criteria rather than criteria for a routine referral. B may appear reasonable for isolated low-risk non-visible haematuria, but delays referral despite her age and persistent dysuria. D may form part of specialist investigation but should not be used to delay an indicated suspected cancer referral; NICE does not require primary-care imaging before referral. E is inappropriate because there is no current microbiological evidence of UTI and the persistent symptoms with sterile haematuria require assessment for malignancy rather than repeated empirical treatment.

Reference: NICE NG12: Suspected cancer: recognition and referral — Bladder cancer, recommendation 1.6.4 (Updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer