skip to main content

Possible bladder cancer — MSRA MCQ

Instant feedback + full explanation. One question, done properly.

ModerateMicrohematuriaPossible bladder cancerMSRA

A 66-year-old woman has non-visible haematuria identified during investigation of fatigue. She has no visible haematuria, dysuria, urinary frequency, loin pain, fever, weight loss, vaginal bleeding or recent urinary instrumentation. She has not undertaken vigorous exercise. A correctly collected midstream urine specimen shows blood 2+ on reagent-strip testing, with negative nitrites and leucocytes; urine culture shows no significant growth. Her eGFR is 78 mL/min/1.73 m², urine ACR is 1.2 mg/mmol and blood pressure is 132/78 mmHg. Full blood count shows a white cell count of 13.4 × 10⁹/L with neutrophilia. She is systemically well and clinical assessment identifies no infective focus. What is the most appropriate next management step?

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

Reveal the answer and explanation

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

This patient meets the NICE NG12 criterion for suspected bladder cancer referral: she is aged 60 years or over and has unexplained non-visible haematuria with a raised white cell count. Her urine culture is negative and there is no clinical focus of infection, so the haematuria and neutrophilia remain unexplained. A suspected cancer pathway referral should therefore be made without delaying for serial testing or primary-care imaging. Repeating urinalysis and the full blood count may be reasonable for isolated low-risk abnormalities that do not meet a referral threshold, but it is inappropriate here because the threshold is already met. Renal tract ultrasound is not a substitute for referral and could delay specialist investigation, which may include cystoscopy and appropriate upper-tract imaging. Nephrology referral would be more appropriate where haematuria is accompanied by features suggesting kidney disease, such as significant albuminuria, declining eGFR, hypertension or an active urinary sediment; these are absent. Empirical antibiotic treatment is not indicated because she has no urinary symptoms, pyuria, nitrites or culture-confirmed infection.

Reference: Suspected cancer: recognition and referral (NG12), Bladder cancer, recommendation 1.6.4 (2015; updated 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer