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Unexplained visible haematuria — MSRA MCQ

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HardHematuriaUnexplained visible haematuriaMSRA

A 56-year-old man presents with a single episode of painless visible haematuria. He has no dysuria, frequency, fever, loin pain, urethral discharge, recent urinary instrumentation or anticoagulant use. He reports mild nocturia but no change from baseline. Urine dipstick is 3+ blood, with negative nitrites and leucocytes; a properly collected midstream urine culture shows no significant growth. His eGFR is 76 mL/min/1.73 m². Abdominal examination is normal. What is the most appropriate management plan today?

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Correct answer: D — Refer today using a suspected cancer pathway for bladder and renal cancer, and offer PSA testing and digital rectal examination concurrently

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

This man requires a suspected cancer pathway referral today for possible bladder and renal cancer. He is aged 45 or over and has unexplained visible haematuria: there is no clinical or microbiological evidence of urinary tract infection, and no alternative benign explanation is supplied. NICE recommends suspected cancer pathway referral in this situation; referral should not be contingent on persistence, repeat testing or initial imaging. Because he has male reproductive organs and visible haematuria, NICE also advises considering PSA testing and digital rectal examination to assess for prostate cancer. These are additional assessments, not gatekeepers for the required bladder/renal cancer referral. A is therefore unsafe because a normal PSA or benign examination would not remove the indication for urgent urological assessment. B incorrectly treats an unsubstantiated infection and delays referral. D may be part of subsequent diagnostic assessment but should not replace the suspected cancer pathway referral. E confuses this presentation with haematuria that occurred during a proven UTI, where persistence or recurrence after successful treatment is the relevant discriminator.

Reference: NICE NG12: Suspected cancer: recognition and referral — recommendations organised by site of cancer (Updated 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer NICE NG12: Suspected cancer: recognition and referral — recommendations organised by site of cancer (Updated 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer NICE QS215: Kidney cancer — Quality statement 1, suspected cancer pathway referral (19 March 2026) — https://www.nice.org.uk/guidance/qs215/chapter/Quality-statement-1-Suspected-cancer-pathway-referral