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Unexplained visible haematuria — MSRA MCQ

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ModerateHematuriaUnexplained visible haematuriaMSRA

A 46-year-old woman presents with one episode of painless visible haematuria. She has no dysuria, frequency, urgency, fever, loin pain, weight loss, vaginal bleeding, recent urinary instrumentation or history of renal stones. Her last menstrual period was 2 weeks ago. Urine dipstick is 3+ for blood with negative nitrites and leucocytes, and a correctly collected midstream urine culture shows no significant growth. Her eGFR is 88 mL/min/1.73 m². What is the most appropriate next management step?

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Correct answer: C — Make a suspected cancer pathway referral for urological assessment

This patient requires a suspected cancer pathway referral. She is aged 45 years or over and has visible haematuria that is unexplained: there is no clinical or microbiological evidence of urinary tract infection, and the history excludes an apparent vaginal source. NICE recommends suspected cancer pathway referral for both bladder and renal cancer assessment in this situation. A single episode is sufficient; recurrent bleeding is not required. A routine urology referral is insufficient because she meets the urgent referral threshold. Repeating urine testing before referral would be appropriate for some presentations of non-visible haematuria, but should not delay referral for unexplained visible haematuria in this age group. Ultrasound may form part of specialist assessment, but a normal ultrasound would not exclude important urothelial pathology and should not be used as a gatekeeper to referral. Empirical antibiotics are inappropriate because she has neither symptoms nor culture evidence of UTI. The normal eGFR supports safe subsequent investigation if contrast imaging is required, but does not alter the referral decision.

Reference: Suspected cancer: recognition and referral (NG12) — Recommendations organised by site of cancer (Updated 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer