Reasoning GP · Algorithm · 1-page summary
Haematuria in adults — visible and non-visible
For: adults with visible haematuria (VH) or dipstick non-visible haematuria (NVH) in primary care. Not for: children (use the haematuria in children algorithm).
Core rule: never let a UTI, an anticoagulant or vaginal atrophy explain haematuria away — recheck the dipstick after treating infection, and refer visible haematuria aged ≥45 (unexplained, or persisting/recurring after a treated UTI) on the suspected cancer pathway.
0Stop — call 999 now
- Haemodynamic instability — tachycardia, hypotension, pallor with heavy VH, or urosepsis with shock → 999 ED. Do not transfer an unstable patient independently.
- Clot retention — VH with inability to pass urine or bladder distension → Same-day emergency/urology assessment; 999 if unstable, collapsing or major ongoing haemorrhage.
- Trauma + haematuria (renal laceration, urethral injury) → Same-day / 999 for imaging.
1Triage — NICE NG12 thresholds, applied precisely
| Finding | Action |
|---|---|
| VH, aged ≥45 | Unexplained (no UTI), or persisting/recurring after a treated UTI → Urgent suspected cancer pathway (urology) |
| NVH, aged ≥60 | Unexplained, with dysuria or raised blood WCC → Urgent suspected cancer pathway |
| Aged ≥60, UTIs | Recurrent or persistent unexplained UTI → consider Non-urgent urology |
| VH, under 45 | Urological assessment, Routine or Urgent by clinical picture |
| Persistent NVH | ≥1+ on 2 of 3 dipsticks, no criteria above → eGFR, ACR, BP; urology or renal by findings |
2Screen — serious causes
- Flank pain + fever/rigors (urosepsis, obstructed stone, pyelonephritis) → Same-day ED.
- Suspected nephritic or nephrotic syndrome → Same-day nephrology discussion.
- Haematuria + ACR ≥30 mg/mmol, ACR ≥70, AKI, rapidly falling eGFR, RBC casts → Urgent nephrology.
- Weight loss + loin mass, mass on imaging, PSA above age threshold or malignant-feeling prostate → Urgent suspected cancer pathway.
- Women ≥55, VH + low Hb, thrombocytosis or high glucose → also consider direct access ultrasound (endometrial cancer).
- Child with unexplained VH (Wilms') → consider ≤48 h very urgent referral.
3Assess
☐ VH or NVH: fresh strip, investigate ≥1+ ☐ Exclude menstruation, exercise, beetroot/rifampicin, catheter trauma ☐ Smoking, dyes/aromatic amines, drugs ☐ BP, abdomen, loins, bladder ☐ MSU if infection suspected ☐ FBC, U&E/eGFR, ACR; clotting if anticoagulated ☐ Men with VH: consider DRE + PSA after discussion (age-specific thresholds)
Not routine in primary care: microscopy to confirm a dipstick, cytology, CT urography (urology selects imaging), awaiting serology before nephrology referral.
4Classify — only if blocks 0–2 are negative
- UTI — LUTS, fever; treat, then recheck the dipstick.
- Stone — loin-to-groin colic → renal colic pathway.
- Glomerular — proteinuria, hypertension, oedema, casts; VH after URTI (IgA) → nephrology, not urology.
- Prostate — LUTS; do not attribute to BPH until referral criteria are assessed.
- Bladder/renal cancer — painless VH, smoker, occupational exposure → apply NG12.
- Uncertain — repeat dipstick, eGFR, ACR, BP; refer by findings.
5Treat today — doses: NICE/SPC, BNF, local formulary
- Lower UTI, non-pregnant woman: nitrofurantoin 100 mg MR BD 3 days (avoid if eGFR <45); trimethoprim 200 mg BD 3 days if contraindicated. Recheck dipstick after.
- Small distal ureteric stone, stable: NSAID + paracetamol; consider off-label tamsulosin 400 micrograms OD; normal hydration.
- Anticoagulated: do not stop routinely; check INR; specialist advice before withholding.
- Smoking cessation → NHS Stop Smoking Service. Vaginal oestrogen for menopausal symptoms never delays investigation.
6Refer routinely and review
- Ureteric stone not passed after 4 weeks → routine urology.
- Persistent NVH in primary care or after negative urology → dipstick, BP, eGFR, ACR annually; nephrology if ACR rises, eGFR falls or hypertension develops.
- After a suspected cancer referral → confirm it was received and booked; chase if not. Document any declined investigation.
7Never reassure by
- A treated UTI — persistent haematuria at NG12 thresholds still needs urgent referral.
- Anticoagulants or antiplatelets — investigate on the same pathway.
- Vaginal atrophy, or a trial of vaginal oestrogen.
- BPH or a raised PSA — both may need assessment.
- A normal ultrasound — it does not exclude bladder cancer.
- Antibiotics prescribed — do not delay investigation when concern is high.
8Safety-net — say it, then document it
999 “Call 999 if you have heavy bleeding or clots, cannot pass urine, collapse or have severe pain.”
Same day: “Contact us the same day if you see new blood in your urine, or get a high fever with urinary symptoms or rapidly worsening loin pain.”
✓Safe to leave primary care only if — all five, documented
No block 0–2 feature
VH or NVH confirmed; contaminants excluded
NG12 age thresholds applied; dipstick rechecked after any UTI
eGFR, ACR and BP done
Referral tracked, safety-net and review date documented
Summary of the full Reasoning GP haematuria algorithm, which holds the history, examination, investigations, stone prevention, follow-up and evidence. Sources: NICE NG12 (suspected cancer, updated April 2026), NICE NG203 (CKD), NICE NG109 (lower UTI), NICE NG118 (renal and ureteric stones), NICE QS215, BAUS/Renal Association haematuria consensus. Clinical reference — follow local pathways and check doses: NICE/SPC, BNF.