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Unexplained non-visible haematuria with leukocytosis — MSRA MCQ

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HardHematuriaUnexplained non-visible haematuria with leukocytosisMSRA

A 66-year-old woman is reviewed after non-visible haematuria was found during a hypertension review. She has no visible haematuria, dysuria, urinary frequency, fever, loin pain, weight loss, vaginal bleeding, recurrent urinary tract infection or recent urinary instrumentation. She is a non-smoker. Three correctly collected midstream urine samples over 6 weeks each show 2+ blood on reagent-strip testing. Nitrites and leucocytes are negative and all cultures show no significant growth. Her urine ACR is 1.6 mg/mmol, eGFR is 74 mL/min/1.73 m² on two measurements 3 months apart, and blood pressure is 128/76 mmHg. Full blood count shows a white cell count of 13.4 × 10⁹/L, confirmed on repeat testing 2 weeks later; haemoglobin and platelet count are normal. She is clinically well and examination is unremarkable. What is the most appropriate referral to arrange today?

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

This patient meets the NICE criterion for a suspected cancer pathway referral for bladder cancer: she is aged 60 years or over and has unexplained non-visible haematuria with a raised white cell count. Dysuria is an alternative qualifying feature, not an additional requirement. The haematuria has been demonstrated repeatedly, urine cultures are negative, and there is no benign infective explanation. A routine urology referral is insufficient because she meets an urgent suspected-cancer threshold. Urgent ultrasound may be part of subsequent assessment, but it should not delay the indicated referral. Repeating investigations again is inappropriate: persistence has already been established and leukocytosis has been confirmed. A renal cancer pathway is not the relevant NICE referral category here; the renal pathway criterion is visible haematuria in people aged 45 years or over, either unexplained or persistent/recurring after treatment of UTI. Her normal ACR, stable eGFR and absence of hypertension escalation or proteinuria also make a glomerular process less likely as the immediate explanation.

Reference: Suspected cancer: recognition and referral (NG12) — Recommendations organised by site of cancer (Updated April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer Suspected cancer: recognition and referral (NG12) — Recommended actions organised by symptom and findings of primary care investigations (Updated April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommended-actions-organised-by-symptom-and-findings-of-primary-care-investigations Chronic kidney disease: assessment and management (NG203) — Recommendations (Updated November 2025) — https://www.nice.org.uk/guidance/ng203/chapter/recommendations