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Non-visible haematuria — MSRA MCQ

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ModerateMicrohematuriaNon-visible haematuriaMSRA

A 61-year-old man attends after non-visible haematuria was identified during an occupational health assessment. He has no visible haematuria, dysuria, urinary frequency, loin pain, fever, weight loss, recent urinary instrumentation or vigorous exercise. He is a former smoker. Two correctly collected midstream urine samples, taken 3 weeks apart, show blood 2+ and blood 1+ on reagent-strip testing. Both are negative for nitrites and leucocytes, and urine cultures show no significant growth. Urine ACR is 1.6 mg/mmol, eGFR is 88 mL/min/1.73 m² and blood pressure is 126/74 mmHg. Full blood count shows a white cell count of 12.9 × 10⁹/L with neutrophilia. This remains 13.2 × 10⁹/L on repeat testing 3 weeks later. He is systemically well and there is no clinical focus of infection. What is the most appropriate next management step?

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

This patient meets the NICE NG12 criterion for suspected bladder cancer referral: he is aged 60 years or over and has unexplained non-visible haematuria with a raised white cell count. The haematuria has been demonstrated on repeat testing, urine culture is negative, and there is no transient explanation such as urinary infection, exercise or instrumentation. The persistent neutrophilia is specifically a qualifying feature even though he has no dysuria. A routine urology referral is less appropriate because this presentation meets the threshold for a suspected cancer pathway referral. Repeating tests in 3 months would delay referral despite the current NG12 criterion already being fulfilled. Nephrology assessment would be more appropriate if there were evidence suggesting intrinsic renal disease, such as significant albuminuria, reduced kidney function, hypertension or other features of glomerular pathology; these are absent. A renal ultrasound may form part of subsequent specialist investigation, but arranging it first should not delay the indicated suspected cancer pathway referral.

Reference: Suspected cancer: recognition and referral (NG12) — Recommended actions organised by symptom and findings of primary care investigations (Updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommended-actions-organised-by-symptom-and-findings-of-primary-care-investigations Chronic kidney disease: assessment and management (NG203) — Recommendations (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations