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Persistent non-visible haematuria with A3 albuminuria — MSRA MCQ

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HardHematuriaPersistent non-visible haematuria with A3 albuminuriaMSRA

A 66-year-old man has had dysuria for 5 weeks. He has never noticed visible haematuria and has no fever, loin pain, urethral discharge, urinary retention or weight loss. Urine dipstick testing on three correctly collected midstream samples shows 2+ blood. All three urine cultures show no significant growth. His blood pressure is 132/78 mmHg. eGFR is 68 mL/min/1.73 m² and 66 mL/min/1.73 m² on repeat testing 4 months later. Early-morning urine ACR is 44 mg/mmol and 48 mg/mmol on repeat testing. He does not have diabetes. Full blood count shows a white cell count of 8.1 × 10⁹/L. What is the most appropriate next management plan?

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Correct answer: E — Make a suspected cancer pathway referral for bladder cancer and refer for nephrology assessment in parallel

Explanation lettering: E = shown as A · A = shown as E

This man requires parallel urological and nephrological assessment. He is over 60 years old with unexplained non-visible haematuria and dysuria, despite repeated negative cultures. NICE NG12 therefore indicates a suspected cancer pathway referral for bladder cancer. The absence of a raised white cell count does not alter this: dysuria alone satisfies the accompanying-feature criterion in someone aged 60 years or over. He also has persistent A3 albuminuria (ACR over 30 mg/mmol on repeat early-morning testing) together with haematuria. NICE CKD guidance recommends specialist renal assessment for this combination, even though eGFR is relatively preserved and stable. A possible lower-tract malignant cause does not justify deferring nephrology referral, because concurrent albuminuria raises the possibility of intrinsic renal disease and independently meets renal referral criteria. B misses the indicated nephrology referral. C risks delaying investigation for bladder cancer. D may form part of investigation, but imaging must not be used as a gatekeeper before an indicated suspected cancer referral and does not replace nephrology assessment. E is inappropriate because both the haematuria and albuminuria have already been shown to persist.

Reference: NICE NG12: Suspected cancer: recognition and referral — Bladder cancer, recommendation 1.6.4 (Last updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer NICE NG203: Chronic kidney disease: assessment and management — Haematuria and referral criteria (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations