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Visible haematuria with concurrent unexplained vaginal discharge — MSRA MCQ

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HardHematuriaVisible haematuria with concurrent unexplained vaginal dischargeMSRA

A 62-year-old woman, who has been postmenopausal for 10 years and does not use HRT, reports one episode of painless bright-red visible haematuria. She has no dysuria, frequency, fever, loin pain or recent urinary instrumentation. A midstream urine sample obtained before any antibiotics shows 3+ blood, with no nitrites or leucocytes; culture shows no significant growth. She also reports a persistent watery vaginal discharge for 5 weeks, which she describes as separate from the blood seen when voiding. There is no postmenopausal bleeding. Full blood count, platelet count and random plasma glucose are normal. What is the most appropriate management plan today?

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Correct answer: C — Arrange a suspected cancer pathway referral for bladder or renal cancer and an urgent direct-access pelvic ultrasound scan

This patient meets two independent NICE NG12 investigation or referral criteria. First, she is over 45 years old with unexplained visible haematuria and no evidence of urinary tract infection; this requires referral using a suspected cancer pathway for possible bladder or renal cancer. A negative culture means that repeating culture before referral would add delay without resolving the indication. Second, in women aged 55 years and over, visible haematuria with unexplained vaginal discharge warrants consideration of an urgent direct-access ultrasound scan for possible endometrial cancer. Normal haemoglobin, platelet count and glucose do not remove this indication because unexplained vaginal discharge alone is sufficient in this clinical context. A delays both pathways. B appropriately addresses the urinary-tract cancer risk but misses the urgent endometrial assessment. C addresses the endometrial risk but under-triages the visible haematuria. D compounds this by delaying the indicated suspected-cancer referral for repeat microbiology despite an already negative culture. The coexistence of two possible cancer-site presentations requires parallel action, rather than selecting one pathway and observing the other.

Reference: NICE NG12: Recommended actions organised by symptom and findings of primary care investigations (Last updated 15 April 2026) — https://www.nice.org.uk/guidance/NG12/chapter/recommended-actions-organised-by-symptom-and-findings-of-primary-care-investigations NICE NG12: Recommended actions organised by symptom and findings of primary care investigations (Last updated 15 April 2026) — https://www.nice.org.uk/guidance/NG12/chapter/recommended-actions-organised-by-symptom-and-findings-of-primary-care-investigations NICE NG12: Suspected cancer: recognition and referral (Published 23 June 2015; last updated 15 April 2026) — https://www.nice.org.uk/Guidance/NG12