Haematuria Algorithm

Safety

Red Flags — Exclude Emergencies & Urgent Malignancy

Done

Haematuria can represent emergency, urgent cancer, or benign pathology. Triage immediately.

Haemodynamic instability Tachycardia, hypotension, pallor with heavy visible haematuria → 999 (massive haemorrhage)

Clot retention / acute urinary retention Visible haematuria with inability to pass urine, bladder distension or suspected clot retention → immediate same-day emergency/urology assessment. 999 if unstable, collapsing or major ongoing haemorrhage

Visible haematuria (frank) in ≥45y Unexplained (no UTI), or persisting/recurring after a treated UTI → urology suspected cancer pathway referral (NICE NG12, updated April 2026). Do not delay referral when malignancy is clinically suspected.

Flank pain + haematuria + fever Rigors, high fever, unwell → same-day ED (urosepsis from obstructing stone or pyelonephritis)

NVH + age ≥60 with dysuria or raised blood WCC Unexplained non-visible haematuria with dysuria or a raised white cell count on a blood test → urology suspected cancer pathway referral (NICE NG12; bladder cancer can mimic UTI)

Weight loss + haematuria + loin mass Constitutional symptoms, palpable renal mass → urology suspected cancer pathway referral (renal cell carcinoma)

Anticoagulation + visible haematuria Never attribute VH solely to anticoagulation or antiplatelets. Investigate using the same clinical pathway.

Post-traumatic haematuria Any trauma mechanism + haematuria → same-day/999 for imaging (renal laceration, urethral injury)

NICE NG12 recommends a urology suspected cancer pathway referral for visible haematuria in adults ≥45y and NVH in adults ≥60y with dysuria or a raised blood white cell count. Earlier-stage diagnosis improves bladder cancer outcomes. Anticoagulation does not remove the need for investigation — an underlying cause must still be excluded.

Diagnose

Classify — Visible vs Non-Visible Haematuria

Done

Establish the type — this determines the entire pathway and urgency of referral.

Visible haematuria (VH)

Patient can see blood in urine. Also called gross / frank haematuria. Should always be clinically explained. Aged ≥45: unexplained VH, or VH persisting/recurring after successful UTI treatment → suspected cancer pathway (NICE NG12). Younger adults: urological or renal assessment according to symptoms, risk factors and examination findings.

Non-visible haematuria (NVH)

Detected on dipstick or MSU only. Previously called microscopic haematuria. Threshold: ≥1+ blood on dipstick (confirmed on 2 out of 3 samples)

Dipstick interpretation

Use a fresh reagent strip; investigate ≥1+ blood. Myoglobinuria and haemoglobinuria give false positives. Routine microscopy is not required to confirm dipstick haematuria (NICE NG203) — send microscopy when a renal cause is suspected (dysmorphic red cells, casts), per local laboratory arrangements.

Exclude contaminants

Menstruation (repeat post-period), beetroot/rifampicin ingestion (pink urine, dipstick negative), vigorous exercise (repeat urinalysis after stopping strenuous exercise), urethral trauma (catheterisation)

Symptomatic vs asymptomatic

Symptomatic (with LUTS, pain, fever) = likely infection/stone first. Asymptomatic = higher cancer risk. Both require investigation if confirmed.

Transient vs persistent

Treat confirmed UTI, then repeat the dipstick after treatment. With no UTI or transient explanation, 2 of 3 positive reagent-strip tests = persistent NVH → assess. Do not delay investigation when clinical concern is high simply because antibiotics have been prescribed.

NVH is common in the general population. Persistent NVH is defined as 2 of 3 positive dipstick samples. UTI can cause NVH that resolves — repeat the dipstick after treatment, but do not delay investigation if clinical concern is high. NICE NG12 thresholds are based on cancer risk modelling: VH in ≥45y or NVH + dysuria/raised blood white cell count in ≥60y warrants urgent urology referral.

Diagnose

Targeted History — Localise the Source & Identify Cause

Done

History localises bleeding to upper or lower tract and narrows the differential significantly.

Timing of haematuria

Initial stream only = urethral/prostate source. Terminal = bladder neck/trigone. Throughout = upper tract, bladder body. Clots = significant bleed

Associated LUTS

Frequency, urgency, nocturia, poor flow, hesitancy → prostate (BPH/cancer), bladder pathology

Pain features

Loin-to-groin colicky pain → ureteric calculus. Dull loin ache → renal tumour, pyelonephritis. Suprapubic pain → cystitis, bladder tumour

Occupational / exposure

Aniline dyes, aromatic amines (leather, printing, rubber industries) → bladder cancer risk. Cyclophosphamide, pioglitazone, phenacetin

Smoking history

Smoking substantially increases bladder cancer risk. Pack years. Current/ex. Biggest modifiable risk factor for transitional cell carcinoma.

Systemic features

Joint pains, rash, oedema, hypertension, recent sore throat/skin infection → glomerulonephritis (IgA nephropathy, post-strep GN, vasculitis)

Family history

Polycystic kidney disease (flank pain, hypertension, palpable kidneys), Alport syndrome, von Hippel-Lindau (renal tumours)

Drugs

Anticoagulants (warfarin, DOACs), antiplatelets (aspirin, clopidogrel). NSAIDs (papillary necrosis if chronic). Cyclophosphamide (haemorrhagic cystitis)

Occupational exposure to aniline dyes/rubber manufacturing increases bladder cancer risk — ask specifically in any haematuria. IgA nephropathy (Berger's disease) is the most common glomerulonephritis worldwide — presents with frank haematuria 24-72h after URTI. Post-streptococcal GN presents 1-3 weeks after throat/skin infection with haematuria, proteinuria, hypertension, and oedema. These require urgent nephrology referral, not urology.

Diagnose

Examination — Abdominal, Renal, and Urological Assessment

Done

Examination guides urgency and helps localise the lesion.

Blood pressure

Hypertension + haematuria + proteinuria = glomerulonephritis until proven otherwise. Hypertension common in PKD. Check both arms.

Abdomen

Ballottable renal mass → renal carcinoma, PKD (bilateral masses). Suprapubic tenderness → cystitis, retention. Bladder distension → clot retention.

Flanks

Renal angle (CVA) tenderness → pyelonephritis, obstructing calculus. Loin mass → renal tumour.

DRE (male)

Prostate size, texture, nodules, asymmetry. Hard/nodular prostate → prostate cancer. Tender/boggy → prostatitis. Consider PSA after discussion.

Pelvic exam (female)

Exclude gynaecological source — cervical abnormalities, uterine tenderness. Vaginal atrophy can cause urinary symptoms and sample contamination — confirm the blood is urinary; do not assume atrophy explains true haematuria.

Oedema / fluid

Peripheral oedema, periorbital puffiness → nephrotic/nephritic syndrome, cardiac/hepatic cause. Assess for ascites.

Skin / joints

Purpuric rash → IgA vasculitis (HSP). Joint disease → SLE, vasculitis (nephrology to guide serology). Skin ulcers → SLE nephritis.

In men with visible haematuria, consider DRE and PSA where clinically appropriate (NICE NG12). Vaginal atrophy should not be assumed to explain true haematuria — if haematuria meets referral criteria, do not delay referral for a trial of vaginal oestrogen. Ballottable renal masses require urgent ultrasound — renal cell carcinoma often presents incidentally or with haematuria alone. The 'classic triad' (haematuria, flank pain, palpable mass) is uncommon.

Diagnose

Investigations — Urinalysis, Bloods & Imaging

Done

Order systematically — urine, bloods, then imaging. Imaging and cystoscopy are selected by urology — CT urography is not routine for every patient.

Urine All

MSU for MC&S where infection is clinically suspected; repeat dipstick after treatment if haematuria persists or if clinically indicated. Urine dipstick: blood, protein, nitrites, leucocytes. Urine cytology is specialist-directed — not a routine primary-care test.

Urine protein

Protein + haematuria → renal cause. ACR (albumin:creatinine ratio) ≥3 mg/mmol = clinically important proteinuria. Confirm ACR 3–70 mg/mmol on a subsequent early-morning sample (not needed if ≥70). Refer to nephrology if ACR ≥30 mg/mmol with haematuria, ACR ≥70 mg/mmol, or AKI, progressive eGFR decline, significant hypertension, systemic disease or another suspected renal disorder (NICE NG203).

Bloods All

FBC (anaemia of malignancy, thrombocytopaenia), U&E/eGFR/creatinine (renal function), coagulation if on anticoagulants

PSA (males)

In men with visible haematuria, consider PSA and DRE where clinically appropriate, after discussing benefits and limitations. Consider UTI/prostatitis, recent ejaculation, instrumentation and urinary retention before testing. Interpret using NG12 age-specific thresholds: 40–49 >2.5; 50–59 >3.5; 60–69 >4.5; 70–79 >6.5 micrograms/L; over 79 clinical judgement. A raised PSA does not automatically explain the haematuria — both may need assessment.

Calcium / urate

Hypercalciuria and hyperuricosuria → renal stones. Serum calcium, urate in recurrent stone-formers

Glomerulonephritis screen

Haematuria with significant proteinuria, AKI, hypertension, oedema, systemic symptoms or active urinary sediment → urgent renal assessment. Nephrology should guide the autoimmune/glomerulonephritis blood panel — do not delay referral awaiting serology.

Imaging Via urology

Do not arrange CT urography routinely. Refer per NICE criteria and local pathways; urology selects imaging and cystoscopy by age, cancer risk, renal function and suspected source. CTU may be needed when upper-tract urothelial disease is suspected and renal function permits. A normal ultrasound does not exclude bladder cancer.

Repeat before investigating

NVH on a single dipstick with UTI — treat UTI, then repeat dipstick. Children with haematuria → use the haematuria in children algorithm, not this adult pathway; unexplained visible haematuria in a child → consider very urgent referral (appointment within 48 hours) for possible Wilms' tumour (NICE NG12). Exercise-related haematuria — repeat urinalysis after stopping strenuous exercise; investigate if it persists, recurs, is visible, or is accompanied by proteinuria, renal impairment or other risk factors.

CT urography involves radiation and iodinated contrast and is not appropriate for every patient — assessment may include renal/bladder ultrasound, CTU or both, depending on context (NICE QS215). Urine cytology is a specialist-directed test and is not a substitute for cystoscopy or upper-tract imaging. PSA has limited sensitivity and specificity for prostate cancer — discuss benefits and limitations before testing. Send urine MC&S where infection is suspected — UTI can confound NVH.

Refer

Referral Pathways — NICE NG12 Cancer Criteria & Nephrology

Done

Apply NICE NG12 thresholds precisely — under-referral risks delayed cancer diagnosis, over-referral wastes suspected cancer pathway capacity.

999

Haemodynamic instability (massive ongoing VH), clot retention with collapse or major haemorrhage, urosepsis with shock → emergency department immediately. Do not transfer an unstable patient independently.

Same-day

Clot retention (stable but unable to void), urosepsis (unwell + fever + haematuria), severe flank pain with fever/rigors, AKI with obstruction or sepsis, suspected nephritic or nephrotic syndrome (same-day nephrology discussion), significant post-traumatic haematuria

Suspected cancer · urology

Visible haematuria ≥45y (unexplained, or persisting/recurring after a treated UTI). NVH ≥60y + dysuria OR raised blood white cell count (NICE NG12, updated April 2026). PSA above the age-specific threshold or malignant-feeling prostate. (Non-urgent, NG12: aged ≥60 with recurrent or persistent unexplained UTI.) Women ≥55 with visible haematuria and low haemoglobin, thrombocytosis or high blood glucose → also consider direct access ultrasound for endometrial cancer (NICE NG12).

Suspected cancer · urology

Renal mass on USS/imaging suspicious for malignancy. Ureteric mass. Bladder mass on USS. Upper tract filling defect on IVU/CTU.

Urgent Nephrology

Haematuria + ACR ≥30 mg/mmol, or ACR ≥70 mg/mmol. Haematuria + AKI. Haematuria + rapidly declining eGFR. Dysmorphic RBCs/casts on microscopy (RBC casts = glomerulonephritis). Systemic vasculitic features (NICE NG203). Suspected nephritic or nephrotic syndrome → same-day nephrology discussion.

Routine Urology

Persistent NVH not meeting suspected cancer criteria — after repeat dipstick, eGFR, ACR and BP, refer to urology or renal services according to findings and local pathway. Visible haematuria under 45 — urological assessment, routine or urgent according to the clinical picture. Ureteric calculus not passing spontaneously after 4 weeks.

Primary care manage

Uncomplicated UTI with NVH — treat UTI, recheck. Genitourinary menopausal symptoms — vaginal oestrogen (never to delay investigation of true haematuria). Exercise-related NVH that resolves on repeat testing with no proteinuria or other risk factors. Small distal calculus with adequate analgesia passing spontaneously.

NICE NG12 (updated April 2026) recommends a suspected cancer pathway referral for unexplained VH ≥45y, or VH persisting/recurring after successful UTI treatment, and for unexplained NVH ≥60y with dysuria or a raised WCC. RBC casts on urine microscopy are pathognomonic of glomerulonephritis and mandate urgent nephrology referral — suspected nephrotic syndrome (heavy proteinuria with oedema) or nephritic syndrome needs same-day discussion with nephrology.

Treat

Treatment — Primary Care Management of Confirmed Causes

Done

Primary care manages UTI, stones (minor), and benign causes. All confirmed malignancy is secondary care.

Uncomplicated lower UTI (non-pregnant women)

Nitrofurantoin 1st line

100mg MR BD × 3 days (uncomplicated). Avoid if eGFR <45 (MHRA/BNF; a 3–7 day course may be used with caution at eGFR 30–44 only for suspected or proven multidrug-resistant infection). Trimethoprim 200mg BD × 3 days if nitrofurantoin CI. Follow local antimicrobial guidance; do not base treatment on dipstick alone. Send MSU for recurrent UTI, treatment failure, atypical symptoms, men, pregnancy, systemic illness or suspected pyelonephritis. Recheck dipstick after treatment.

Small distal ureteric calculus

Medical expulsive therapy

Clinically stable, no infection, AKI, uncontrolled pain or obstruction needing intervention: discuss conservative management and consider off-label tamsulosin 400 micrograms OD per NICE NG118/local urology policy (counsel on postural hypotension and ejaculatory effects). Adequate analgesia (NSAIDs + paracetamol). Encourage normal hydration — do not advise forced fluid loading.

BPH with haematuria

BPH/LUTS pathway

Manage BPH via the BPH/LUTS pathway, not this haematuria protocol. Do not attribute haematuria to BPH until it has been assessed against referral criteria; exclude prostate cancer first.

Genitourinary menopausal symptoms

Vaginal oestrogen

Consider for genitourinary menopausal symptoms or recurrent UTI (e.g. estradiol 10 micrograms pessary nightly for 2 weeks, then twice weekly). Confirm the blood is urinary rather than vaginal. Do not use vaginal oestrogen to delay investigation of true visible haematuria or persistent haematuria meeting referral criteria.

Anticoagulant review

Do NOT stop anticoagulant

Investigate haematuria in anticoagulated and antiplatelet-treated patients using the same pathway. Do not stop routinely. Check INR where relevant and seek specialist/emergency advice before withholding or reversing, except in life-threatening haemorrhage where emergency protocols apply.

Exercise-induced haematuria

Repeat urinalysis

Repeat urinalysis after stopping strenuous exercise. If haematuria persists, recurs, is visible, or is accompanied by proteinuria, renal impairment or other risk factors, investigate through the appropriate urological or renal pathway.

Next steps: see UTI in women · UTI in men · Benign prostate enlargement · Male LUTS · Recurrent UTI

NICE NG109 (lower UTI): nitrofurantoin is first-line for uncomplicated lower UTI — trimethoprim resistance is common, making nitrofurantoin the preferred empirical choice; follow local resistance data. Tamsulosin for medical expulsive therapy (MET) is supported by NICE NG118 (renal and ureteric stones, 2019), which advises considering an alpha-blocker (off-label) for selected distal ureteric stones under 10 mm.

Lifestyle

Prevention & Risk Reduction — Modifiable Factors

Done

Address modifiable risk factors for the underlying cause — reduces recurrence and cancer risk.

Smoking cessation Reduces bladder cancer risk. Refer to NHS Stop Smoking Service. Single most important lifestyle intervention for TCC prevention.

Hydration Stone formers: drink 2.5–3 litres of water a day (adjust for renal function and heart failure), add fresh lemon juice, avoid carbonated drinks (NICE NG118). Do not force fluids during acute colic.

Diet (stone prevention) Tailor to stone composition or specialist metabolic assessment — e.g. reduce oxalate-rich foods (spinach, nuts, chocolate) if calcium oxalate stones. Reduce animal protein (uric acid stones). Normal calcium intake — NOT low calcium diet.

Occupational safety Aniline dyes, aromatic amines, polycyclic aromatic hydrocarbons → bladder cancer risk. Ensure appropriate PPE use. Report to occupational health. Notify RIDDOR if occupational bladder cancer confirmed.

Weight management Obesity increases RCC risk. Metabolic syndrome also increases urinary stone risk via hyperuricosuria.

Pelvic floor exercises For women with recurrent UTI — incomplete bladder emptying increases infection risk. A raised post-void residual needs investigation.

Cranberry products Cranberry capsules/juice have limited, modest evidence for reducing recurrent UTI. Not proven in single-episode UTI. Advise as adjunct, not replacement for treatment.

NSAID review Chronic NSAID use → papillary necrosis + haematuria. Review necessity. Switch to paracetamol where possible. Particularly important in elderly with recurrent NVH.

Smoking cessation is the most powerful cancer prevention strategy for bladder cancer — smoking is the leading modifiable risk factor. A 5-year randomised trial (Borghi et al, J Urol 1996) showed that high water intake (urine volume of at least 2 L/day) cut stone recurrence from 27% to 12%. Paradoxically, LOW calcium diets increase calcium oxalate stone risk by increasing intestinal oxalate absorption — patients should be counselled on this counter-intuitive fact (Curhan et al, NEJM 1993).

Safety

Follow-Up — Safety-Netting & Monitoring Plan

Done

Close the loop — haematuria must never be left unresolved without a diagnosis.

After UTI treatment

Repeat dipstick after completing UTI treatment. Renal function (U&E/eGFR) if stone or renal pathology. Confirm MSU clearance if treated for infection.

After a suspected cancer referral

Confirm the referral was received and an appointment booked; chase if not (diagnosis or cancer ruled out within the 28-day Faster Diagnosis Standard). Tell the patient to attend the first appointment offered. Document in notes if patient declines investigation.

Annual

Persistent NVH managed in primary care — repeat dipstick, BP, eGFR and ACR annually while haematuria persists (NICE NG203). If findings change → review investigation plan. If new symptoms develop → re-investigate or re-refer urgently.

Post-stone

Recurrent or high-risk stone formers only: 24-hour urine and metabolic assessment via urology/renal stone services — to guide dietary/pharmacological prevention

Post-cancer treatment

Bladder and renal cancer surveillance is urology-led and follows the patient's documented specialist schedule. GP role: support attendance, manage cardiovascular/renal risk, review relevant symptoms and act on specialist correspondence.

Safety-net 999

Heavy visible bleeding, clots, inability to pass urine, collapse, severe pain → 999 immediately

Safety-net same-day

Any new VH, frank haematuria, high fever + urinary symptoms, rapidly worsening loin pain, significant medication side effects

Unresolved NVH

If urological assessment is negative and NVH persists, monitor BP, eGFR and ACR annually in primary care. Refer to nephrology if proteinuria increases, ACR exceeds referral thresholds, eGFR declines, hypertension develops, or there are systemic/urinary features of glomerular disease.

A negative urological evaluation does not establish IgA nephropathy — persistent isolated NVH has a broad differential, including thin-basement-membrane disease, IgA nephropathy, other glomerular disorders and benign unexplained haematuria. Ongoing monitoring (BP, eGFR, ACR) detects progression. Unresolved NVH is not benign — a 7-year follow-up study (Khadra et al) showed 2% developed urological malignancy during surveillance. Document all referrals and patient decisions regarding investigation carefully.