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Persistent invisible haematuria with dysuria, leucocytosis and A3 albuminuria — MSRA MCQ

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HardMicrohematuriaPersistent invisible haematuria with dysuria, leucocytosis and A3 albuminuriaMSRA

A 61-year-old woman presents with 7 weeks of dysuria and urinary frequency. She has no visible haematuria, fever, loin pain, vaginal bleeding or recent vigorous exercise. Three appropriately collected midstream urine specimens show blood 2+, blood 1+ and blood 2+ on reagent strip; all cultures show no significant growth. Her full blood count shows a persistent neutrophilia, with white cell counts of 12.6 × 10⁹/L and 12.9 × 10⁹/L 3 weeks apart. There is no clinical focus of infection. Early-morning urine ACR is 44 mg/mmol and 47 mg/mmol on samples 13 weeks apart. Her eGFR is stable at 72 mL/min/1.73 m², blood pressure is 128/76 mmHg and she does not have diabetes. She takes rivaroxaban for atrial fibrillation. What is the most appropriate next management plan?

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

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

This woman requires two concurrent referral pathways. She has persistent invisible haematuria because at least 2 of 3 reagent-strip tests are positive. At age 61, unexplained non-visible haematuria with dysuria and a raised white cell count meets NICE criteria for a suspected cancer pathway referral for bladder cancer. Negative cultures and the absence of another infective focus make a urinary infection explanation unlikely. Rivaroxaban does not remove the need to investigate an otherwise unexplained haematuria signal. She also has confirmed A3 albuminuria (ACR greater than 30 mg/mmol on repeat early-morning testing) with haematuria. NICE recommends nephrology specialist assessment for this combination, even though eGFR is preserved and blood pressure is normal. This may represent glomerular disease and should not be deferred while urological malignancy is investigated. A is incomplete: renal ultrasound is appropriate in CKD with persistent invisible haematuria, but it must not delay indicated referrals. B misses the renal referral criterion. D inappropriately attributes haematuria to anticoagulation and delays cancer assessment. E may become relevant if hypertension or another indication for renin–angiotensin system blockade develops, but it neither addresses the suspected-cancer criterion nor replaces nephrology assessment.

Reference: NICE NG12: Suspected cancer: recognition and referral — haematuria and dysuria recommendations (2015; updated 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommended-actions-organised-by-symptom-and-findings-of-primary-care-investigations NICE NG203: Chronic kidney disease: assessment and management — referral criteria and haematuria (2021; checked 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations