Blood seen within the urine by patient or doctor (VISIBLE) or identified on urine dipstick or MSU (NON-VISIBLE).
Risk of urothelial malignancy: visible haematuria ~20%, non-visible ~3%
2WW Criteria: suspected bladder / renalcancer
Aged 45 and over and have:
- Unexplained visible haematuria without urinary tract infection or
- Visible haematuria that persists or recurs after successful treatment of urinary tract infection
Aged 60 and over and have:
- unexplained non-visible haematuria, persistent for > 2 weeks, and either dysuria or a raised white cell count on a blood test
Imaging suspicious of bladder or renal cancer
For haematuria patients that do not fulfil 2WW criteria:
- Refer urgently (this will go direct to cystoscopy)
- Request urgent renal tract USS at time of referral
- PSA for all men with visible and non-visible haematuria
- A 'trace' of haematuria on dipstick should be considered negative, and only ≥ 1+ should be considered positive because of the sensitivities of the test sticks.
- If asymptomatic then 2 out of 3 dipsticks should be positive before further investigation is warranted (≥ 1+ blood).
- Do not attribute microscopic haematuria to aspirin or warfarin.
Management of recurrent haematuria:
- Previously investigated recurrent haematuria management is contentious, ongoing visible bleeding may need repeat investigation, discussion or re-referral is advised according to duration/severity etc.
- Previously investigated recurrent non-visible haematuria with an apparent cause identified at initial assessment (eg. enlarged prostate, UTI, stone, warfarin use etc) need not be re-referred.
- Patients under 40 with non-visible haematuria and proteinuria should have albumin/creatinine ratio measured and initially be referred to a renal physician as per CKD guidelines.
NICE, 2015. Suspected cancer: recognition and referral
Mr Christopher Blake, Consultant Urologist, RCHT
Dr Stephanie Jackson, GP Lead Urology
Reviewed: July 2018