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Non-visible haematuria with dysuria — MSRA MCQ

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HardMicrohematuriaNon-visible haematuria with dysuriaMSRA

A 64-year-old man reports 3 weeks of dysuria. He has no visible haematuria, fever, loin pain, urethral discharge, weight loss, recent urinary instrumentation or vigorous exercise. He takes apixaban for atrial fibrillation and has never smoked. Two correctly collected midstream urine specimens, taken 10 days apart, show blood 2+ and blood 1+ on reagent-strip testing; microscopy confirms red cells in both samples. Both cultures show no significant growth. Urine ACR is 1.4 mg/mmol, eGFR is 78 mL/min/1.73 m², blood pressure is 128/76 mmHg, and full blood count is normal. What is the most appropriate next management step?

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

This man requires referral on a suspected cancer pathway for bladder cancer. NICE NG12 recommends this for people aged 60 years or over with unexplained non-visible haematuria and either dysuria or a raised white cell count. He meets the age criterion and has dysuria; a raised white cell count is not additionally required. Repeated negative cultures, absence of transient precipitants and microscopy-confirmed haematuria make urinary infection or sample contamination less likely explanations. Apixaban can precipitate bleeding, but anticoagulant treatment does not exclude an underlying urinary tract lesion and should not be used as a reason to defer haematuria investigation. Empirical antibiotics are inappropriate with repeatedly negative cultures and no supportive urinalysis features. Routine urology referral under-triages a patient who meets NG12 suspected cancer criteria. Nephrology assessment would be more appropriate if there were evidence suggesting medical renal disease, such as significant albuminuria/proteinuria, impaired renal function, hypertension or an active urinary sediment; these are absent here.

Reference: NICE NG12: Suspected cancer: recognition and referral — Bladder cancer, recommendation 1.6.4 (Last updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer NHS Borders: Referral guideline for investigation of haematuria in adults in primary care (2026) — https://rightdecisions.scot.nhs.uk/media/1704/haeumaturia-in-adults.pdf