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Persistent non-visible haematuria — MSRA MCQ

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ModerateMicrohematuriaPersistent non-visible haematuriaMSRA

A 60-year-old man has non-visible haematuria detected during a hypertension review. He has no visible haematuria, fever, loin pain, weight loss, recent instrumentation or vigorous exercise. He reports mild dysuria for 3 weeks. Three correctly collected midstream urine cultures show no significant growth. Urine reagent-strip testing on three samples over 5 weeks shows blood 2+, blood negative and blood 1+. Urine ACR is 1.8 mg/mmol, eGFR is stable at 86 mL/min/1.73 m² and blood pressure is 130/78 mmHg. Full blood count shows a white cell count of 13.1 × 10⁹/L with neutrophilia. There is no clinical focus of infection. What is the most appropriate next management step?

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

Reveal the answer and explanation

Correct answer: D — Refer using a suspected cancer pathway for bladder cancer

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

This man meets the NICE NG12 criterion for suspected bladder cancer pathway referral: he is aged 60 years or over and has unexplained non-visible haematuria with dysuria and a raised white cell count. The repeatedly negative urine cultures and absence of another infective focus make infection an inadequate explanation. His normal ACR and stable eGFR make a primary glomerular process less likely as the immediate priority. A is appropriate for persistent isolated invisible haematuria only after appropriate investigation for urinary tract malignancy and where no cancer-referral criterion is met. B may form part of renal tract assessment in some pathways, but imaging should not delay or substitute for the indicated suspected cancer pathway referral. C under-triages a presentation that meets NICE criteria for urgent suspected bladder cancer assessment. D is tempting because neutrophilia can be reactive, but NICE does not require confirmation of the raised white cell count before referral when unexplained non-visible haematuria is present in a person aged 60 years or over. The dysuria independently reinforces the same referral threshold.

Reference: NICE NG12: Suspected cancer: recognition and referral — Bladder cancer, recommendation 1.6.4 (2015; page current August 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer NICE NG203: Chronic kidney disease: assessment and management — Managing isolated invisible haematuria (2021; page current August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations