skip to main content

Visible haematuria with raised age-specific PSA — MSRA MCQ

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

HardHematuriaVisible haematuria with raised age-specific PSAMSRA

A 44-year-old man presents after one episode of painless visible haematuria. He has no dysuria, fever, loin pain, urethral discharge, recent urinary instrumentation or anticoagulant use. Urine dipstick is 3+ for blood with negative nitrites and leucocytes, and a correctly collected midstream urine culture shows no significant growth. He reports no lower urinary tract symptoms. Digital rectal examination shows a smooth, non-tender prostate. PSA, taken after the negative urine culture result, is 3.1 micrograms/L. His eGFR is 86 mL/min/1.73 m². What is the most appropriate referral to arrange today?

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

Reveal the answer and explanation

Correct answer: D — Arrange a suspected cancer pathway referral for prostate cancer

This man should have a suspected cancer pathway referral for prostate cancer. NICE advises considering PSA testing and digital rectal examination in men with visible haematuria. Where there are possible prostate-cancer symptoms, including visible haematuria, NICE advises considering a suspected cancer pathway referral when PSA exceeds the age-specific threshold. For men aged 40–49 years, this threshold is greater than 2.5 micrograms/L; his PSA of 3.1 micrograms/L therefore meets the referral criterion. A smooth prostate does not overrule an age-adjusted raised PSA. A suspected cancer pathway referral for bladder or renal cancer is not indicated under the haematuria criterion because he is under 45 years old, despite having unexplained visible haematuria. Routine urology referral is therefore less appropriate than the indicated prostate cancer pathway. Repeating PSA before referral would be reasonable if a reversible cause of PSA elevation were present, such as recent urinary infection, but infection has been excluded and there is no recent instrumentation. Safety-netting alone risks delaying investigation of a PSA result above the relevant symptomatic threshold.

Reference: NICE NG12: Suspected cancer: recognition and referral — recommendations organised by site of cancer (2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer NICE NG12: Suspected cancer: recognition and referral — recommended actions organised by symptom and primary care findings (2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommended-actions-organised-by-symptom-and-findings-of-primary-care-investigations