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Recurrent visible haematuria after successfully treated urinary tract infection — MSRA MCQ

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HardHematuriaRecurrent visible haematuria after successfully treated urinary tract infectionMSRA

A 58-year-old woman is reviewed 5 weeks after treatment for acute cystitis. At the initial presentation she had dysuria, urinary frequency and visible haematuria. A midstream urine sample obtained before antibiotics grew >10⁵ CFU/mL Escherichia coli susceptible to the prescribed antibiotic. Her dysuria, frequency and visible haematuria resolved completely within 48 hours of completing treatment. She now reports 2 days of painless visible haematuria. She has no dysuria, frequency, urgency, fever, loin pain, vomiting, vaginal bleeding, weight loss or recent urinary instrumentation. A midstream urine sample obtained before any further antibiotics shows no significant growth. Her eGFR is 76 mL/min/1.73 m² and urine ACR is 1.8 mg/mmol. What is the most appropriate management today?

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Correct answer: E — Refer using a suspected cancer pathway for urological assessment of possible bladder or renal cancer

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

This woman requires referral using a suspected cancer pathway. She is aged 45 years or over and now has recurrent visible haematuria after successful treatment of a microbiologically confirmed UTI. The first episode can reasonably be attributed to cystitis because it occurred with urinary symptoms and a positive pre-treatment culture, and it resolved fully after culture-directed treatment. However, the new episode is painless, occurs without symptoms of infection, and the repeat culture shows no significant growth. It therefore meets NICE criteria for suspected cancer pathway referral for both bladder and renal cancer. A is inappropriate because repeat testing or surveillance delays referral when visible haematuria has recurred after successful UTI treatment. B under-triages a presentation meeting suspected cancer pathway criteria. C is not justified because there are no current infective symptoms and culture is negative. E may be part of subsequent specialist investigation, but primary-care imaging should not be used to determine whether a qualifying suspected cancer referral is made; a normal ultrasound would not exclude important urothelial pathology.

Reference: NICE NG12: Suspected cancer: recognition and referral — recommendations organised by site of cancer (2015; current online guidance checked 16 August 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 findings of primary care investigations (2015; current online guidance checked 16 August 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommended-actions-organised-by-symptom-and-findings-of-primary-care-investigations