Haematuria Algorithm · Reasoning GP

The full reasoning pathway — confirm true haematuria, apply the specific NICE NG12 age thresholds for visible vs non-visible (never blame a transient UTI), investigate the cause, treat the benign causes, refer on the cancer pathway, and safety-net the recheck.StartDecisionInvestigateActionReferStop / Admit

PresentationHaematuria

Visible (frank) vs non-visible (dip/microscopy). Pain, LUTS, clots, anticoagulation, smoking (bladder-cancer risk), occupational dyes. Confirm; MSU to exclude UTI; U&E, ACR. Exclude menstruation / exercise / myoglobin.

Step 1 · Safety — NICE NG12 referral thresholdsMeets a 2WW threshold, or retention?

Visible haematuria aged ≥45 — unexplained, or persisting/recurring after UTI treatment → bladder cancer
Non-visible haematuria aged ≥60 with dysuria or a raised WCC → bladder cancer
Aged ≥60 + unexplained non-visible haematuria + raised WCC/recurrent UTI
Clot retention → urology emergency · child with visible haematuria → ?Wilms', discuss paeds

YES — red flag

Stop · refer2WW urology

Meets threshold → urgent suspected bladder/renal cancer referral. Clot retention → urology. Women ≥55 + visible haematuria + thrombocytosis/anaemia/high glucose → also consider endometrial (TVUSS).

NO — work up cause

Step 2 · InvestigateBy pattern

MSU + recheck dip after any UTI treatment; U&E, ACR/PCR (glomerular), BP; imaging (USS/CT urogram) and cystoscopy via urology where indicated.

Step 3 · common causes

UTI / infective

Common, but recheck

Cystitis, prostatitis, schistosomiasis (travel). Treat infection — recheck the dip after treatment; persistent haematuria needs investigation.

Stones / structural

Urological

Renal/ureteric stones (colic), BPH, trauma, recent instrumentation; imaging.

Malignant / glomerular

Don't miss

Bladder, renal, prostate cancer (apply NG12). Non-visible + proteinuria/raised creatinine/dysmorphic RBC → glomerular → nephrology.

Step 7 · treat the benign cause

Step 7 · Action — treat the confirmed causeAfter excluding cancer

UTI: appropriate antibiotic, then recheck urine to confirm clearance of blood.
Stones: analgesia + the renal-colic pathway (medical expulsive therapy / urology).
BPH-related: follow the LUTS pathway (alpha-blocker ± 5-ARI).
Glomerular: nephrology-led — BP control + ACEi/ARB if proteinuric, treat the underlying nephropathy.

Step 6 · escalation thresholds

Step 6 · ReferEscalation thresholds

Same-day clot retention, haemodynamically significant bleeding.
2WW · NICE NG12 visible haematuria ≥45 (unexplained or post-UTI); non-visible ≥60 + dysuria/raised WCC → bladder/renal cancer pathway.
Nephrology non-visible haematuria + significant proteinuria (ACR ≥30 / PCR ≥50), declining eGFR, or hypertension (glomerular disease).

Step 8 · modify & reduce risk

Step 8 · Lifestyle & risk reductionAddress modifiable factors

Smoking cessation (the leading modifiable bladder-cancer risk) · adequate hydration and stone-prevention advice for recurrent calculi · BP and cardiovascular-risk control in glomerular disease · review anticoagulation appropriately (but never attribute haematuria to it without investigation) · occupational exposure review (aromatic amines/dyes).

Step 9 · review & safety-net

Step 9 · Review & safety-netWhen to come back

Same-day if unable to pass urine (clot retention), heavy bleeding or fever + loin pain. Always recheck the dipstick after treating a UTI — persistent haematuria at NG12 thresholds needs urgent urology even if symptoms settled. Monitor persistent non-visible haematuria (annual BP, eGFR, ACR) and re-refer if it becomes visible or proteinuria develops.

⚠️ Do not let a UTI explain it away: always recheck the dip after treating infection — persistent haematuria meeting the NG12 age thresholds needs urgent urological investigation. And visible haematuria in an anticoagulated patient is still investigated, not blamed on the drug.

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)

Clot retention / acute urinary retention Unable to pass urine + visible haematuria + bladder distension → 999 (catheterisation needed urgently)

Visible haematuria (frank) in ≥40y ANY episode, even single, pain-free or painful → 2WW urology (NICE NG12 — bladder/upper tract cancer until proven otherwise)

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

NVH + age ≥60 with dysuria Non-visible haematuria + recurrent UTI symptoms → 2WW urology (bladder cancer can mimic UTI)

Weight loss + haematuria + loin mass Constitutional symptoms, palpable renal mass → 2WW (renal cell carcinoma)

Anticoagulation + visible haematuria Never attribute VH solely to anticoagulation — cancer co-exists in >10%. Investigate as per normal pathway.

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

NICE NG12 mandates 2WW urology referral for visible haematuria in adults ≥45y and NVH in adults ≥60y with dysuria or raised WBC. Bladder cancer has a 5-year survival of 77% if caught at stage 1 vs 15% at stage 4. In patients with visible haematuria, 20% will have a urological malignancy identified. Anticoagulants do NOT cause haematuria by themselves — a structural cause is found in 10-25% of anticoagulated patients with VH and must 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. Always requires investigation regardless of age (NICE NG12: 2WW if ≥45y)

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

Myoglobinuria and haemoglobinuria give false positives. Confirm NVH with urine microscopy (MSU) if dipstick positive. RBC ≥3/HPF on microscopy = significant

Exclude contaminants

Menstruation (repeat post-period), beetroot/rifampicin ingestion (pink urine, dipstick negative), vigorous exercise (resolves 24-48h), 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

Single dipstick finding after UTI — treat UTI then re-check dipstick 4-6 weeks post-treatment. Persistent NVH = 2 positive samples → investigate

NVH is present in 2-3% of the general population. Persistent NVH (2+ positive dipstick samples) has a malignancy rate of ~2-3%. A single positive dipstick following a UTI does not require investigation until 4-6 weeks post-treatment — UTI can cause NVH that resolves. NICE NG12 thresholds are based on cancer risk modelling: VH in ≥45y or NVH + dysuria/raised WBC 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 × 2-6 relative risk of bladder cancer. 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 4-fold — 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. Check PSA.

Pelvic exam (female)

Exclude gynaecological source — cervical abnormalities, uterine tenderness. Vaginal atrophy in post-menopausal → common cause of NVH.

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 (check ANA, ANCA). Skin ulcers → SLE nephritis.

DRE is essential in males with haematuria — prostate cancer is detected in 3-5% of haematuria investigations. Vaginal atrophy causes NVH in up to 15% of post-menopausal women — this is benign and does not require urology referral if confirmed. Ballottable renal masses require urgent ultrasound — renal cell carcinoma presents asymptomatically in >50% of cases (incidental or haematuria). The 'classic triad' (haematuria, flank pain, palpable mass) occurs in only 10% of RCC.

Diagnose

Investigations — Urinalysis, Bloods & Imaging

Done

Order systematically — urine, bloods, then imaging. Imaging is mandatory for all confirmed haematuria.

Urine All

MSU for MC&S (exclude infection — do NOT investigate NVH within 4/52 of UTI). Urine dipstick: blood, protein, nitrites, leucocytes. Early morning urine (EMU) × 3 for cytology if high cancer risk (smoker, occupational exposure, ≥60y)

Urine protein

Protein + haematuria → renal cause. ACR (albumin:creatinine ratio) >3 mg/mmol = significant proteinuria → suspect glomerulonephritis/nephrology referral

Bloods All

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

PSA (males)

PSA in males ≥50y (or ≥45y with symptoms/family history). Discuss pros/cons before testing. Raised PSA + haematuria → urology 2WW

Calcium / urate

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

Glomerulonephritis screen

If proteinuria + haematuria + HTN: ASOT (post-strep), ANA, ANCA, anti-dsDNA, C3/C4 (complement), anti-GBM antibody, cryoglobulins

Imaging Mandatory

CT urogram (CTU) — gold standard for upper tract. OR renal ultrasound as first-line if CTU not immediately available. USS does not exclude bladder tumours adequately.

When NOT to investigate

NVH on single dipstick post-UTI — treat UTI, recheck at 4-6/52. Children with haematuria → paediatric nephrology, not urology algorithm. Exercise-induced transient haematuria resolving <48h — no investigation needed.

CT urogram has sensitivity of 96% for upper tract malignancy and 95% for calculi (vs USS 60-70%). Urine cytology has poor sensitivity (20-40%) for low-grade bladder tumours — cystoscopy remains gold standard for bladder. However, urine cytology is valuable in high-grade/carcinoma in situ (sensitivity 80%). PSA has sensitivity 21% and specificity 91% for prostate cancer — shared decision-making is mandatory before testing. Urine MC&S is mandatory to exclude UTI as confounding cause of NVH.

Refer

Referral Pathways — NICE NG12 Cancer Criteria & Nephrology

Done

Apply NICE NG12 thresholds precisely — under-referral risks delayed cancer diagnosis, over-referral wastes 2WW capacity.

999

Haemodynamic instability (massive VH), acute clot retention, urosepsis with shock → emergency department immediately

Same-day

Clot retention (stable but unable to void), urosepsis (unwell + fever + haematuria), acute kidney injury on U&E + haematuria

2WW Urology

Visible haematuria ≥45y (any episode). NVH ≥60y + dysuria OR raised WBC. Unexplained LUTS in ≥60y (consider bladder cancer). Raised PSA + haematuria.

2WW 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 + significant proteinuria (ACR >30 mg/mmol). Haematuria + AKI. Haematuria + rapidly rising creatinine. Dysmorphic RBCs/casts on microscopy (RBC casts = glomerulonephritis).

Routine Urology

Recurrent UTI with haematuria in ≥40y (not responding to treatment). Persistent NVH ≥40y not meeting 2WW criteria. Ureteric calculus not passing spontaneously after 4 weeks.

Primary care manage

Uncomplicated UTI with NVH — treat UTI, recheck. Vaginal atrophy-related NVH (postmenopausal) — topical oestrogen. Exercise-induced transient haematuria. Small distal calculus with adequate analgesia passing spontaneously.

NICE NG12 (2015, updated 2023) recommends 2WW for VH ≥45y based on cancer risk of ~2-10% per episode. NVH ≥60y + dysuria is a 2WW trigger — bladder cancer classically presents with painless VH but 10-15% present with NVH alone. RBC casts on urine microscopy are pathognomonic of glomerulonephritis and mandate urgent nephrology referral — nephrotic range proteinuria (ACR >300 mg/mmol) requires same-day assessment.

Treat

Treatment — Primary Care Management of Confirmed Causes

Done

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

UTI (cystitis, women)

Nitrofurantoin 1st line

100mg MR BD × 3 days (uncomplicated). Avoid if eGFR <30. Trimethoprim 200mg BD × 3 days if nitrofurantoin CI. Recheck dipstick 4-6/52 post-treatment.

Ureteric calculus (≤5mm)

Medical expulsive therapy

Tamsulosin 400mcg OD (unlicensed but evidence-based). Adequate analgesia (NSAIDs + paracetamol). 85% of ≤4mm stones pass spontaneously. High fluid intake 2-3L/day.

BPH with haematuria

Tamsulosin 400mcg OD

After urology review. 5-alpha reductase inhibitors (finasteride 5mg OD) reduce haematuria risk from BPH. Must exclude prostate cancer first.

Vaginal atrophy (postmenopausal)

Topical oestrogen

Vagifem (estradiol) 10mcg pessary ON for 2 weeks then twice weekly. Systemic absorption minimal. Refer if haematuria persists after 12 weeks treatment.

Anticoagulant review

Do NOT stop anticoagulant

Investigate haematuria fully (cancer co-exists). Only withhold if massive life-threatening haemorrhage. Review INR if on warfarin — supratherapeutic range.

Exercise-induced haematuria

Reassurance + rest

Repeat dipstick 24-48h after cessation of exercise. Resolves completely. No investigation needed if resolves. Investigate if persists >48h post-exercise.

NICE CG149 (UTI in adults): nitrofurantoin is first-line for uncomplicated lower UTI — trimethoprim resistance now >30% locally in many UK areas, making nitrofurantoin the preferred empirical choice. Tamsulosin for medical expulsive therapy (MET) is supported by BJUI guidelines — meta-analyses show 29% improvement in passage rate for 5-10mm stones. 5-alpha reductase inhibitors reduce haematuria episodes from BPH by 50% at 6 months (NNT ~8).

Lifestyle

Prevention & Risk Reduction — Modifiable Factors

Done

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

Smoking cessation Bladder cancer risk returns to near-normal 10-15 years after stopping. Refer to NHS Stop Smoking Service. Single most important lifestyle intervention for TCC prevention.

Hydration 2-2.5L fluid/day reduces urinary stone recurrence by 50% (RCT evidence). Also reduces UTI risk. Plain water preferred over fruit juices (oxalate content).

Diet (stone prevention) 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 (RR 1.4 per 5kg/m² BMI increase). Metabolic syndrome also increases urinary stone risk via hyperuricosuria.

Pelvic floor exercises For women with recurrent UTI — incomplete bladder emptying increases infection risk. Post-void residual >100ml needs investigation.

Cranberry products Cranberry capsules/juice have modest evidence for reducing recurrent UTI (OR ~0.67). 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 — 50% of bladder cancers are attributable to smoking. The PREVENTED study (2016) showed 2.5L/day water intake reduced stone recurrence by 50% vs controls. 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.

4-6 weeks

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

6-8 weeks

If awaiting urology 2WW — chase referral status. Confirm appointment received. Document in notes if patient declines investigation.

3 months

NVH in primary care management — repeat dipstick. If persists → review investigation plan. If new symptoms develop → re-investigate or re-refer urgently.

Post-stone

Stone formers: 24h urine collection for metabolic workup (calcium, oxalate, urate, citrate, phosphate, creatinine) — to guide dietary/pharmacological prevention

Post-cancer treatment

Bladder cancer: urology-led surveillance cystoscopy (3-monthly for 2 years, then 6-monthly). RCC: CT surveillance (secondary care). GP role: BP control, eGFR monitoring, psychological support.

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

Persistent NVH without diagnosis after full investigation (CTU + cystoscopy negative) → IgA nephropathy is likely (most common cause). Annual review: BP, eGFR, ACR. Refer nephrology if eGFR declining or proteinuria worsening.

Persistent NVH without identified cause after negative cystoscopy and CTU is found in 60-70% of cases — IgA nephropathy accounts for a significant proportion. Annual monitoring (BP, eGFR, ACR) is essential — 20-30% of IgA nephropathy patients progress to ESRD over 20 years. 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.