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Visible haematuria associated with urinary tract infection — MSRA MCQ

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ModerateHematuriaVisible haematuria associated with urinary tract infectionMSRA

A 73-year-old woman is reviewed on day 3 of a 5-day course of culture-directed oral antibiotics for acute cystitis. At presentation she had dysuria, frequency and visible haematuria. A midstream urine sample obtained before antibiotics grew >10^5 CFU/mL Escherichia coli susceptible to the prescribed antibiotic. Her dysuria and frequency have now resolved, but she noticed pink urine once this morning. She is afebrile and systemically well, with no loin pain, vomiting, urinary retention, vaginal bleeding or recent instrumentation. Her eGFR is 71 mL/min/1.73 m². What is the most appropriate management plan today?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: E — Complete antibiotic treatment, confirm that visible haematuria resolves, and refer using a suspected cancer pathway if it persists or recurs

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

The urine culture was obtained before antibiotics and confirms a susceptible E. coli lower UTI, a recognised cause of visible haematuria. She is improving clinically but has not yet completed treatment; therefore, treatment cannot yet be considered successful. The NICE suspected-cancer criterion in this setting is visible haematuria that persists or recurs after successful treatment of UTI. She should complete treatment and be clearly safety-netted to report any further visible blood; persistence at completion or later recurrence requires suspected cancer pathway referral because she is over 45. A is inappropriate because she has no sepsis, obstruction, renal impairment, uncontrolled bleeding or other feature requiring emergency assessment. B is premature because the haematuria has occurred during, rather than after successful completion of, treatment for a microbiologically confirmed UTI. C bypasses the appropriate referral pathway and is not required while infection is being treated successfully. E incorrectly assumes that microbiological confirmation removes the need to establish resolution; ongoing or recurrent visible haematuria after treatment must not be attributed automatically to UTI.

Reference: NICE NG12: Suspected cancer: recognition and referral — Recommended actions organised by symptom and findings of primary care investigations (2015; updated 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommended-actions-organised-by-symptom-and-findings-of-primary-care-investigations NICE QS215: Kidney cancer — Quality statement 1: Suspected cancer pathway referral (19 March 2026) — https://www.nice.org.uk/guidance/qs215/chapter/Quality-statement-1-Suspected-cancer-pathway-referral