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Persistent isolated non-visible haematuria — MSRA MCQ

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ModerateMicrohematuriaPersistent isolated non-visible haematuriaMSRA

A 59-year-old woman has incidental non-visible haematuria detected during a hypertension review. She has no visible haematuria, dysuria, urinary frequency, loin pain, fever, weight loss, urinary tract infection symptoms, recent instrumentation or vigorous exercise. Samples were collected outside menstruation. She is a current smoker (25 pack-years). Urine reagent-strip testing on three correctly collected early-morning samples over 6 weeks shows blood 1+, negative and blood 2+. All three midstream urine cultures show no significant growth. Urine ACR is 1.6 mg/mmol, eGFR is stable at 82 mL/min/1.73 m², blood pressure is 128/76 mmHg on amlodipine, and full blood count is normal. What is the most appropriate next management plan?

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Correct answer: D — Arrange annual monitoring of urine haematuria, ACR, eGFR and blood pressure, with safety-netting for new urological symptoms

This is persistent invisible haematuria: two of three appropriately collected reagent-strip samples are positive at 1+ or greater. She has no albuminuria, impaired kidney function or hypertension that would indicate renal referral. NICE recommends annual repeat testing for haematuria, albuminuria/proteinuria, GFR and blood pressure when persistent invisible haematuria occurs without proteinuria. A suspected cancer pathway referral is not indicated on these facts. NICE NG12 specifies this for unexplained non-visible haematuria only in people aged 60 years or over who also have dysuria or a raised white cell count. Smoking increases background bladder-cancer risk but does not itself meet this NICE referral threshold; she should nevertheless be safety-netted to report visible haematuria or new urinary symptoms. Routine urology referral is therefore not the guideline-directed next step. Nephrology referral would be appropriate if ACR were above 30 mg/mmol with haematuria, or if another renal referral criterion were met. Urine microscopy should not be used to confirm a positive reagent-strip result in this context.

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