Haematuria

Scope

  • Dipstick urine testing for Non-Visible Haematuria in asymptomatic individuals is not recommended
  • The National Screening Committeee (NSC) supports the limitation of urine dipstick test screening of asymptomatic individuals in Primary and Secondary care
  • Please consider reviewing the practice of urine testing with multi-dipsticks for new patients, pre-operative assessments, quality and outcome framework (QOF) and other patients who are asymptomatic
  • A very small number of patients under 45 years of age get bladder cancer and some with Non Visible Haematuria do too. So there will be small but important groups that are symptomatic or a GP is worried about where referral case by case may still be appropriate outside of the guidelines. The guidelines cover more than 95% of clinical scenarios.

Out of scope

Male or female patients with symptoms suggestive of a urinary infection and visible haematuria diagnose and treat the infection before considering referral.

Assessment

Signs and Symptoms

Visible Haematuria

  • Plasma creatinine/ estimated Glomerular Filtration Rate (eGFI)

Differential Diagnoses

Manage Ureteric Colic or urinary tract infection (UTI)

  • UTI in males
  • UTI in females
  • Ureteric Colic

Red Flags

Visible Haematuria with no UTI symptoms

Investigations

A digital rectal examination and a prostate-specific antigen (PSA) test ( after counselling) are recommended for patients with symptoms of haematuria.

  • Exclude transient causes including UTI
For Visible Haematuria:
  • Full Blood Count
  • Creatinine
  • Blood Pressure
  • MSU
For Asymptomatic Non Visible Haematuria:

Ensure not due to menstruation in women (menstruating females may have non-visible haematuria for 3 days prior to and 5 days post menstruation. Non-visible haematuria may also be present for 3 days post intercourse).

  • Repeat dipstick to confirm
    • If more than 1+ of Non-Visible Haematuria in 2 out of 3 dipsticks, 1 week apart
  • If patient under 60 years old
    • Full Blood Count, Creatinine, ACR/PCR and Blood Pressure
      • Renal ultrasound
  • If patient older than 60 years old this is a 2ww referral if associated with raised WBC count on a blood test
    • It would be advisable to do the following investigations but do not delay referral
      • Full Blood Count, Creatinine and Blood Pressure

Referral

Referral Criteria

Include in referral letter where available:

  • Full Blood Count
  • Creatinine and
  • Blood Pressure
Refer to 2ww Haematuria clinic if patient:
  • 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 with dysuria.
    • Unexplained non-visible haematuria with raised white cell count on a blood test.

Unexplained haematuria refers to patients who do not currently have conditions that can cause haematuria e.g. urinary stone disease and UTI.

Dysuria is defined as burning or discomfort in the urethra on voiding.

Menstruating females may have non-visible haematuria for 3 days prior to and 5 days post menstruation. Non-visible haematuria may also be present for 3 days post intercourse. Please exclude these prior to referral.

Refer to Nephrology
  • Patients under 45 with Visible Haematuria
    • include BP, renal function and ACR
  • Patients under 60 years old with non-visible haematuria if:
    • Proteinuria or raised serum creatinine
    • eGFR less than 60mls/min
    • Urine albumin to creatinine ratio (ACR) more than 30
    • Protein-creatinine ratio (PCR) more than 50
    • Blood pressure (BP) more than 140/90
    • Abnormal ultrasound (USS)
    • Include Full Blood Count, Creatinine ACR/PCR and Blood Pressure

Patients do not need referral:

  • If patient under 60 years old with non-visible haematuria and all of the following are normal:
    • No proteinuria on urine dipstick
    • Normal serum creatinine
    • eGFR greater than 60mL/minute
    • ACR less than 30
    • PCR less than 50
    • BP less than 140/90
    • USS normal
  • These patients should then have annual assessment of BP, U+E and ACR/PCR (whilst haematuria persists)

Referral Instructions

Referral to 2ww Haematuria Clinic

Refer using e-Referrals

  • Specialty: 2WW
  • Clinic Type: 2WW Urology
  • Service: 2WW Urology –NDHCT – NDDH - RBZ
Referral to Nephrology

Refer using e-Referrals.

  • Specialty: Nephrology
  • Clinic Type: Nephrology
  • Service: DRSS-Northern – Urology – New Devon CCG – 99p

Referral Forms

DRSS referral form

North Devon 2WW referral form

Supporting Information

Evidence

NSC Laitner 2002

Link to full reference guide to NICE referral guidelines for suspected cancer

Pathway Group

This guideline has been signed off by the Northern Locality on behalf of NEW Devon CCG.

Publication date: January 2017

 

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