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Unexplained non-visible haematuria with dysuria — MSRA MCQ

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ModerateHematuriaUnexplained non-visible haematuria with dysuriaMSRA

A 61-year-old woman presents with 6 weeks of persistent dysuria. She has never had visible haematuria. She has no fever, loin pain, urinary frequency, vaginal discharge, vaginal bleeding, weight loss or recent urinary instrumentation. Urine reagent-strip testing of 3 correctly collected midstream samples over 6 weeks shows 2+ blood on each occasion. Nitrites and leucocytes are negative on each sample, and all 3 urine cultures show no significant growth. Her white cell count is 6.4 × 10⁹/L, eGFR is 79 mL/min/1.73 m² and early-morning urine ACR is 1.6 mg/mmol. What is the most appropriate next management step?

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

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

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

This woman is aged 60 or over and has unexplained non-visible haematuria with dysuria. Repeated negative urine cultures make bacterial UTI an unlikely explanation. NICE NG12 recommends a suspected cancer pathway referral for bladder cancer in people aged 60 or over with unexplained non-visible haematuria plus either dysuria or a raised white cell count. She meets this threshold through dysuria; a normal white cell count does not alter the indication. A is inappropriate because persistent haematuria with this symptom combination requires prompt cancer-pathway assessment rather than surveillance. B underestimates the urgency specified by NICE. C is initially tempting because dysuria commonly reflects UTI, but repeated sterile cultures and absent nitrites/leucocytes make empirical treatment inappropriate and risk delaying investigation. D would be appropriate if there were evidence suggesting glomerular disease or CKD progression, such as significant albuminuria, impaired renal function, hypertension, or haematuria with proteinuria. Her normal ACR and preserved eGFR make a primary nephrological process less likely in this presentation.

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