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Haematuria Care Pathway Overview

This pathway is focused on the management of haematuria. It has been published in response to feedback that has suggested that some GPs may be unsure when it comes to the management of non-visible haematuria, which may potentially be leading to patients being referred unnecessarily through the 2 week wait pathway.

In 2015, NICE updated the guidelines on referral from primary care for patients with suspected cancer. These guidelines are complex, and downgraded the clinical urgency of referral for most patients with non-visible haematuria, thus removing them from the 2 week wait pathway.

However, the following British Association of Urological Surgeons / Renal Association guidelines should still apply, meaning that the following patients should be referred for urological investigation.

  • All patients with symptomatic Non Visible Haematuria regardless of age
  • All patients with asymptomatic Non Visible Haematuria aged ≥40 years old (other than those who have had previous negative Urological investigations for this)

Please click the relevant flowchart box to be taken directly to textual information.

                   

Presentation

Otherwise referred to as ‘microscopic haematuria’ or ‘dipstick positive haematuria’. This is further sub-divided as follows:

  • Symptomatic Non-Visible Haematuria - symptoms such as new unexplained lower urinary tract symptoms (LUTS):  especially frequency, urgency, dysuria; or upper urinary tract symptoms e.g. loin pain
  • Asymptomatic Non-Visible Haematuria. Incidental detection in the absence of LUTS or upper urinary tract symptoms

Otherwise referred to as ‘macroscopic haematuria’ or ‘gross haematuria’. Urine is coloured pink or red (or, on occasion like cola in acute glomerulonephritis). Symptom reported by patient or as seen by health professional. Requires consideration of other (rare) causes of discoloured urine (myoglobinuria, haemoglobinuria, beeturia, drug discoloration – rifampicin, doxorubicin)

Red Flags
  • Painless visible haematuria
  • Recurrent or persistent UTI associated with haematuria in those aged ≥40 years
  • Abdominal mass clinically or on imaging

2ww Criteria – as per NICE Guidance:

  • Refer via 2ww route for suspected bladder cancer if patient is: 
    • Aged 45 and over and has:
      • 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 has unexplained non-visible haematuria and either dysuria or  
                   a raised white cell count on a blood test
  • Refer via 2ww route for suspected renal cancer if patient is:
    • aged 45 and over and has:
      • Unexplained visible haematuria without urinary tract infection
        OR
      • Visible haematuria that persists or recurs after successful treatment of urinary tract infection
Differential Diagnosis

Transient causes to be excluded:

  • Urinary tract infection (UTI)
  • Exercise induced haematuria or rarely myoglobinuria
  • Menstruation
Initial Assessment

What is significant haematuria?

  1. Any single episode of Visible Haematuria
  2. Any single episode of symptomatic Non Visible Haematuria (in absence of UTI or other transient causes).
  3. Persistent asymptomatic Non Visible Haematuria (in absence of UTI or other transient causes). Persistence is defined as 2 out of 3 dipsticks positive for Non Visible Haematuria.

  • Make clear distinction between non-visible and visible haematuria
  • Smoking history – smoking approximately doubles the risk of bladder cancer

Transient causes that need to be excluded before establishing the presence of significant haematuria are:

  • Urinary tract infection (UTI) Haematuria in association with UTI is not uncommon. Following treatment of UTI, a dipstick should be repeated to confirm the post-treatment absence of haematuria. It should be remembered that UTI (regardless of haematuria) can be the first presentation of significant genito-urinary pathology, and should be further investigated if clinically indicated. UTI is most readily excluded by a negative dipstick result for both leucocytes and nitrites. Otherwise an MSU negative for pyuria and culture are required.
  • Exercise induced haematuria or rarely myoglobinuria (Visible Haematuria and Non Visible Haematuria)
  • Menstruation.

N.B. The presence of haematuria (Visible Haematuria or Non Visible Haematuria) should not be attributed to anti-coagulant or anti-platelet therapy and patients should be evaluated regardless of these medications.

Abdominal examination for masses, consider DRE in men to assess prostate (mainly for men with unexplained visible haematuria).

  • Exclude UTI and/or other transient cause.
  • Plasma creatinine/eGFR.
  • Measure proteinuria on a random sample. Send urine for protein:creatinine ratio (PCR) or albumin:creatinine ratio (ACR) on a random sample (according to local practice). N.B. 24 hour urine collections for protein are rarely required. An approximation to the 24 hour urine protein or albumin excretion (in mg) is obtained by multiplying the ratio (in mg/mmol) x10.
  • Blood pressure
  • Send mid stream urine sample for MC&S if UTI suspected
Primary Care Management

Non-visible haematuria:

Follow pathway to determine management – referral urgency according to updated 2ww guidelines.

Visible haematuria:

Refer for Urological assessment unless clear evidence of urinary tract infection (symptoms, MC&S,results response to antibiotics)

When to Refer

Urological Referral

In 2015, NICE updated the guidelines on referral from primary care for patients with suspected cancer. These guidelines are complex, and have downgraded the clinical urgency of referral for most patients with non-visible haematuria, thus removing them from the 2 week wait pathway.

However, the following British Association of Urological Surgeons / Renal Association guidelines should still apply, meaning that the following patients should be referred for urological investigation.

  • All patients with symptomatic Non Visible Haematuria regardless of age
  • All patients with asymptomatic Non Visible Haematuria aged ≥40 years old (unless previous negative urological investigation for this)

The risk of significant pathology in patients with visible haematuria means that management of these patients is relatively straightforward in primary care – unless there is clear documented evidence of a urinary tract infection, the default position for the GP should be an urgent 2 week wait referral to a haematuria clinic for urological investigation

Nephrological referral

For patients who have had a urological cause excluded, or have not met the referral criteria for a urological assessment, a nephrology referral should be considered. The need for a nephrology referral in this situation depends on factors other than simply the presence of haematuria. See NICE chronic kidney disease guidelines for further information.

Ongoing Primary Care Monitoring

Patients not meeting criteria for referral to urology or nephrology, or who have had negative urological or nephrological investigations, need long term monitoring due to the uncertainty of the underlying diagnosis.

Patients should be monitored for the development of:

  • voiding LUTS
  • visible haematuria
  • significant or increasing proteinuria
  • progressive renal impairment (falling eGFR)
  • hypertension (noting that the development of hypertension in older people may have no relation to the haematuria and therefore not increase the likelihood of underlying glomerular disease).
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