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Unexplained visible haematuria — MSRA MCQ

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ModerateHematuriaUnexplained visible haematuriaMSRA

A 52-year-old man presents after a single episode of painless visible haematuria. He has no dysuria, fever, loin pain, urethral discharge, recent urinary instrumentation or anticoagulant use. A properly collected midstream urine sample shows 3+ blood with negative nitrites and leucocytes; urine culture shows no significant growth. He has nocturia and hesitancy that have been unchanged for 3 years. Digital rectal examination shows a smooth, symmetrically enlarged prostate. PSA is 2.9 micrograms/L. His eGFR is 81 mL/min/1.73 m². What is the most appropriate management plan today?

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Correct answer: C — Arrange a suspected cancer pathway urology referral for assessment of bladder and renal cancer

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

This man requires referral using a suspected cancer pathway. NICE recommends this for people aged 45 years and over with unexplained visible haematuria without urinary tract infection, for both bladder and renal cancer assessment. He is 52 years old, has had visible haematuria, and has no clinical, dipstick or culture evidence that infection explains the episode. A single qualifying episode is sufficient; recurrence is not required. His chronic stable lower urinary tract symptoms and symmetrically enlarged prostate may be consistent with benign prostatic enlargement, but do not provide a safe explanation that removes the haematuria referral indication. PSA testing and digital rectal examination are appropriate considerations in men with visible haematuria. However, his PSA is below NICE's age-specific threshold for suspected prostate cancer referral in those aged 50–59 years, and this does not exclude bladder or renal malignancy. B delays the indicated referral. C is inappropriate because imaging may form part of pathway assessment, but referral should follow the clinical threshold rather than await an abnormal scan. D incorrectly makes management dependent on repeat PSA. E wrongly requires recurrence before action.

Reference: NICE NG12: Suspected cancer: recognition and referral — recommendations organised by site of cancer (2015; current NICE page checked August 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer NICE NG12: Recommended actions organised by symptom and findings of primary care investigations (2015; current NICE page checked August 2026) — https://www.nice.org.uk/guidance/NG12/chapter/recommended-actions-organised-by-symptom-and-findings-of-primary-care-investigations