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Visible haematuria associated with culture-confirmed lower urinary tract infection — MSRA MCQ

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HardHematuriaVisible haematuria associated with culture-confirmed lower urinary tract infectionMSRA

A 67-year-old woman presents with 2 days of dysuria, urinary frequency and visible haematuria. She has no fever, rigors, loin pain, vomiting, urinary retention or vaginal bleeding. This is her first episode of visible haematuria. She has a 30 pack-year smoking history. A properly collected midstream urine sample, obtained before antibiotics, grows >10⁵ CFU/mL Escherichia coli susceptible to nitrofurantoin. Her eGFR is 78 mL/min/1.73 m². What is the most appropriate next management plan?

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Correct answer: D — Start culture-directed antibiotics and safety-net that persistent or recurrent visible haematuria after successful treatment requires suspected cancer pathway referral

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

This is a culture-confirmed lower urinary tract infection causing a first episode of visible haematuria. She is clinically stable, with no features suggesting upper-tract infection, sepsis, obstruction or retention requiring same-day hospital assessment. Although she is over 45 and has a smoking history, NICE distinguishes visible haematuria occurring with a confirmed UTI from haematuria that is unexplained, persists, or recurs after successful UTI treatment. The appropriate immediate action is therefore culture-directed treatment of the UTI with explicit safety-netting. A is premature: age and smoking increase concern, but the current haematuria has an identified infectious cause and has not yet persisted or recurred following successful treatment. B is not indicated without loin pain, systemic illness, renal impairment, suspected stone, obstruction or another upper-tract concern. D uses persistent bacteriuria as the referral trigger; the relevant trigger is persistent or recurrent visible haematuria after successful treatment, not a positive post-treatment culture alone. E is also inappropriate because routine referral neither reflects the current infection-first sequence nor provides the required urgent suspected-cancer pathway if haematuria subsequently persists or recurs.

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