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

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ModerateHematuriaNon-visible haematuria with raised white cell countMSRA

A 64-year-old man attends for review of hypertension. He has not noticed visible haematuria and reports no dysuria, fever, loin pain, urinary frequency, weight loss or recurrent urinary tract infection. A correctly collected midstream urine sample is negative for nitrites and leucocytes, and culture shows no significant growth. Urine dipstick is 2+ for blood. His full blood count shows a white cell count of 13.1 × 10⁹/L; repeat testing 1 week later confirms a white cell count of 12.8 × 10⁹/L. eGFR is 78 mL/min/1.73 m² and early-morning urine ACR is 1.4 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: C — Refer using a suspected cancer pathway for bladder cancer

Explanation lettering: C = shown as B · B = shown as C

This man should be referred using a suspected cancer pathway for bladder cancer. NICE NG12 recommends this for people aged 60 years and over with unexplained non-visible haematuria plus either dysuria or a raised white cell count. He is 64 years old, has non-visible haematuria without evidence of infection, and has persistent leukocytosis. Normal ACR and preserved eGFR make a primary glomerular cause less likely and do not alter the cancer-referral criterion. A is attractive because non-visible haematuria is often rechecked, but NICE does not require repeated dipsticks before referral when the age and raised-white-cell-count criterion is met. C underestimates the required urgency. D may form part of subsequent specialist assessment but should not delay the suspected cancer pathway referral. E is inappropriate because he has no urinary symptoms, pyuria, nitrites or significant growth on culture to support UTI.

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