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Persistent unexplained non-visible haematuria with dysuria — MSRA MCQ

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HardHematuriaPersistent unexplained non-visible haematuria with dysuriaMSRA

A 62-year-old woman presents with 6 weeks of dysuria described as urethral burning at the end of micturition. She has not seen blood in her urine. She has no fever, loin pain, vaginal bleeding, vaginal discharge, urinary frequency, urgency, weight loss or recent instrumentation. Three correctly collected midstream urine samples over 5 weeks each show 2+ blood on reagent-strip testing, negative nitrites and leucocytes, and no significant growth on culture. Her white cell count is 6.8 × 10⁹/L, eGFR is 82 mL/min/1.73 m² and two early-morning urine ACR measurements are 1.2 mg/mmol and 1.5 mg/mmol. She does not take anticoagulants. What is the most appropriate management today?

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

This woman requires a suspected cancer pathway referral for bladder cancer. She is aged 60 or over and has unexplained non-visible haematuria with dysuria, which meets NICE NG12 referral criteria. The haematuria is persistent across correctly collected samples, and repeated negative cultures, absent pyuria and lack of systemic features make urinary infection an inadequate explanation. Normal renal function and repeatedly normal ACR make a glomerular process less likely and do not provide a reason to defer urological assessment. A renal and bladder ultrasound may form part of secondary-care investigation, but arranging imaging first should not delay the indicated suspected cancer pathway referral. Empirical antibiotic treatment is inappropriate because repeated cultures do not support bacterial UTI. Nephrology referral would be more appropriate if haematuria were accompanied by significant albuminuria, reduced kidney function, hypertension or another feature suggesting intrinsic renal disease. Further surveillance is inappropriate because the age-and-symptom threshold for urgent cancer-pathway assessment has already been met.

Reference: Suspected cancer: recognition and referral (NG12) — Recommendations organised by site of cancer (Last updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer Chronic kidney disease: assessment and management (NG203) — Recommendations (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations