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Non-visible haematuria with raised white cell count — MSRA MCQ

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ModerateMicrohematuriaNon-visible haematuria with raised white cell countMSRA

A 60-year-old man attends after blood was detected on urine testing performed during a pre-operative assessment. He has no visible haematuria, dysuria, frequency, urgency, loin pain, fever, weight loss, recent urinary instrumentation or vigorous exercise. He is a lifelong non-smoker. Two correctly collected midstream urine samples, taken 3 weeks apart, show blood 2+ and blood 1+ on reagent-strip testing. Both samples are negative for nitrites and leucocytes, and urine cultures show no significant growth. Urine ACR is 1.4 mg/mmol, eGFR is 90 mL/min/1.73 m², and blood pressure is 128/76 mmHg. Full blood count shows a white cell count of 12.6 × 10⁹/L with neutrophilia. Repeat testing 3 weeks later shows a white cell count of 12.9 × 10⁹/L. He remains systemically well and there is no clinical focus of infection. What is the most appropriate next management step?

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

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

This man meets the NICE NG12 criterion for a suspected cancer pathway referral for bladder cancer: he is aged 60 years or over and has unexplained non-visible haematuria with a raised white cell count. The haematuria has been confirmed on reagent-strip testing, cultures are negative, and there is no infective, menstrual, exercise-related or instrumentation-related explanation. His persistent neutrophilia without a clinical focus supports the relevant NG12 risk combination. A normal ACR, eGFR and blood pressure make a primary glomerular process less likely and do not remove the cancer-referral indication. B is initially attractive because persistent non-visible haematuria often warrants urological assessment, but NICE specifies the faster suspected cancer pathway when the age and raised-white-cell-count criterion is met. C would be appropriate only if the referral threshold were not met and further clarification of transient haematuria were required. D may form part of specialist investigation but should not delay the indicated referral; NICE does not recommend primary-care imaging as a prerequisite in this presentation. E applies to persistent isolated invisible haematuria after appropriate malignancy assessment in people without a cancer-pathway indication, not to this higher-risk combination.

Reference: NICE NG12: Suspected cancer: recognition and referral, Bladder cancer, recommendation 1.6.4 (Last updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer