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Non-visible haematuria meeting suspected bladder cancer referral criteria — MSRA MCQ

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ModerateHematuriaNon-visible haematuria meeting suspected bladder cancer referral criteriaMSRA

A 60-year-old woman has incidental non-visible haematuria during review of hypertension. She has never had visible haematuria and has no dysuria, frequency, urgency, fever, loin pain, weight loss, vaginal bleeding or recent urinary instrumentation. Reagent-strip testing of three correctly collected midstream urine samples over 6 weeks shows 2+ blood on each occasion. Nitrites and leucocytes are negative on each sample, and all three urine cultures show no significant growth. Her white cell count is 12.6 × 10⁹/L, with neutrophils 9.0 × 10⁹/L; repeat testing 2 weeks later shows a white cell count of 12.4 × 10⁹/L. She is otherwise well. Her blood pressure is 128/76 mmHg, eGFR is 84 mL/min/1.73 m², and early-morning urine ACR is 1.9 mg/mmol. What is the most appropriate management plan today?

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Correct answer: D — Arrange a suspected cancer pathway referral for bladder cancer

This patient meets the NICE threshold for a suspected cancer pathway referral for bladder cancer: she is aged 60 or over and has unexplained non-visible haematuria with a raised white cell count. The haematuria has been demonstrated repeatedly, and urinary tract infection has been reasonably excluded by absent urinary symptoms, negative nitrite/leucocyte testing and three negative cultures. The repeat raised white cell count supports that this is not an isolated laboratory variation. A non-urgent urology referral is insufficient because NICE specifies a suspected cancer pathway referral for this combination of age, non-visible haematuria and raised white cell count. Repeating testing in 3 months would delay referral despite the referral criterion already being met. Empirical antibiotics are inappropriate because there is no clinical or microbiological evidence of UTI. Nephrology assessment would be more appropriate if there were features suggesting renal parenchymal disease, such as significant albuminuria, impaired or declining eGFR, hypertension difficult to control, or systemic features; these are absent here.

Reference: NICE NG12: Suspected cancer: recognition and referral — Bladder cancer, recommendation 1.6.4 (2015; current guidance checked August 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer