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Isolated persistent invisible haematuria — MSRA MCQ

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HardMicrohematuriaIsolated persistent invisible haematuriaMSRA

A 59-year-old woman has incidental non-visible haematuria identified during a cardiovascular risk review. She has no visible haematuria, dysuria, urinary frequency, loin pain, fever, weight loss, recent urinary instrumentation or vigorous exercise. Samples were collected outside menstruation. She is a current smoker (32 pack-years). Three correctly collected early-morning urine samples over 8 weeks show blood 1+, negative and blood 2+ on reagent strip. All three midstream urine cultures show no significant growth. Her white cell count is 12.5 × 10⁹/L and 12.8 × 10⁹/L on repeat testing 3 weeks later, with neutrophilia and no clinical focus of infection. Urine ACR is 1.7 mg/mmol, eGFR is stable at 88 mL/min/1.73 m² and blood pressure is 126/78 mmHg. What is the most appropriate next management plan?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: B — Arrange annual primary-care monitoring of dipstick haematuria, ACR, eGFR and blood pressure while haematuria persists.

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

This is persistent invisible haematuria: 2 of 3 reagent-strip samples are positive at 1+ or greater. NICE advises that microscopy is not required to confirm a positive dipstick result. She has no albuminuria, reduced eGFR or hypertension, so this is isolated persistent invisible haematuria rather than evidence of CKD requiring nephrology assessment. NICE recommends annual monitoring of haematuria, albuminuria or proteinuria, GFR and blood pressure while isolated persistent invisible haematuria continues. Her neutrophilia and sterile urine make infection an inadequate explanation, and smoking increases clinical concern. However, the NICE suspected-cancer-pathway criterion for unexplained non-visible haematuria with either dysuria or a raised white cell count applies from age 60 years. At age 59, she does not meet this defined threshold. A suspected cancer referral becomes appropriate if she develops visible haematuria, reaches the relevant NG12 threshold with continuing unexplained findings, or develops qualifying symptoms. A is therefore premature under NG12. B would be appropriate if CKD or a renal referral criterion were present; neither applies. C conflicts with NICE advice not to use microscopy to confirm dipstick haematuria. D is unnecessary because her ACR is normal and there is no indication that unconfirmed proteinuria is driving management.

Reference: NICE NG203: Chronic kidney disease: assessment and management — Haematuria and referral criteria (2021; checked 15 August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG12: Suspected cancer: recognition and referral — Bladder cancer (2015; updated 2026; checked 15 August 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer