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Non-visible haematuria with dysuria — MSRA MCQ

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ModerateMicrohematuriaNon-visible haematuria with dysuriaMSRA

A 63-year-old man presents with 5 weeks of dysuria. He has no visible haematuria, fever, loin pain, urethral discharge, weight loss or recent urinary instrumentation. He has not undertaken vigorous exercise. He is a current smoker. A correctly collected midstream urine sample is negative for nitrites and leucocytes but shows blood 2+ on reagent-strip testing. Urine culture shows no significant growth. His white cell count is normal, urine ACR is 1.8 mg/mmol, eGFR is 86 mL/min/1.73 m² and blood pressure is 128/76 mmHg. 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: D — Refer using a suspected cancer pathway for bladder cancer

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

This man meets the NICE NG12 criterion for suspected bladder cancer pathway referral: he is aged 60 years or over and has unexplained non-visible haematuria with dysuria. His negative urine culture makes infection an unlikely explanation for the haematuria and dysuria. Referral should not be delayed to establish persistence with further dipsticks. A is initially attractive because NICE defines persistent invisible haematuria as 2 of 3 positive reagent-strip tests when distinguishing persistent from transient isolated haematuria. However, that approach is not required before acting on the separate NG12 cancer-referral criterion. B is inappropriate because there is no microbiological evidence of UTI and empiric treatment would delay assessment. C may appear a reasonable urological investigation, but primary care urine cytology is not a substitute for the specified suspected cancer pathway referral. D would be appropriate for persistent isolated invisible haematuria without proteinuria after considering malignancy risk, but this patient has dysuria at the age threshold for urgent referral. Normal ACR and stable eGFR make a nephrology referral criterion unlikely.

Reference: NICE NG12: Suspected cancer: recognition and referral — Bladder cancer, recommendation 1.6.4 (2015; current NICE page checked 15 August 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer NICE NG203: Chronic kidney disease: assessment and management — Haematuria, recommendations 1.1.16 to 1.1.19 (2021; current NICE page checked 15 August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations