REMEDY : BNSSG referral pathways

Haematuria

Checked: 12-11-2018 by Rob.Adams Next Review: 11-11-2019

Introduction

Introduction

Haematuria (both visible and non-visible) is a common finding in primary care. However, management of haematuria and who to refer can be difficult to navigate. The new NICE cancer guidelines help to clarify which patients should be referred for possible cancer but do not clarify how patients who fall outside of this group should be managed. The referral service together with local urologists have therefore developed some guidelines for referrers:

Definitions

Can be visible - VH (previously gross/frank/macroscopic) or non-visible - NVH (previously microscopic or dipstick positive)

Can be symptomatic or asymptomatic.

Dipping urine for non-visible haematuria (e.g using multistix) in asymptomatic patients is not recommended as it is not a valid screening test and can lead to unnecessary investigations.

Non Visible Haematuria (NVH)

Testing for NVH

  • Only do urine dip for blood if there is a clinical indication, it is not a good screening test for cancer.
  • The definition of NVH is 1+ blood on dipstick on more than 2 occasions 6 weeks apart. Most dipstick tests no longer include 'Trace' which was previously not considered significant.
  • Microscopy should not routinely be done to exclude haematuria as this is less sensitive than testing strips and may lead to false negatives.

Consider the following before referral:

  • Exclude transient NVH (UTI or excerise) or spurious causes (e.g menstruation, atrophic vaginitis).
  • Check urine albumin creatine ratio (ACR), UE and BP.
  • If a patient over 50 with NVH has been previously investigated and no urological cause found, then persistent NVH does not need further urological investigation.  Patients should however have annual BP, eGFR and urine ACR to screen for chronic kidney disease.

Referral for NVH

Patients aged 60 years and older with NVH and either dysuria or raised white cell count should be referred via 2WW.

All other patients aged 50 years and older with persistent unexplained non- visible haematuria should be referred to urology via urgent referral outside of 2WW (unless 2WW criteria above are met).

Patients aged less than 50 with asymptomatic non-visible haematuria do not usually need urology referral. Screening for chronic kidney disease should be undertaken and consider referral to nephrology if the following  guidelines are met:

NICE CKD guidelines (2016)

For any other patients not falling into above categories or if referrers would like more specific advice then they should consider using the Urology A and G service.

 

The British Association of Urological Surgeons (BAUS) have also produced summary guidelines for the investigation and management of haematuria.

 

Visible Haematuria

It is important to exclude underlying causes of visible haematuria such as infection or stones. If no underlying cause is found on primary care assessment or haematuria persists or recurs following successful treatment of UTI then referral should be made with urgency according to age of the patient (see referral section below)

Referral for visible haematuria

Refer patients with unexplained visible haematuria without UTI ('Unexplained’ haematuria refers to patients where UTI and urinary stone disease have been excluded):

  • If age 45 or over refer via 2WW.
  • If age less than 45 refer urgently to urology via eRS.

Refer patients with visible haematuria that persists or recurs after successful treatment of UTI:

  • If age 45 or over refer via 2WW.
  • If age less than 45 refer urgently to urology via eRS.

Red Flags

See Urology 2WW section for further advice on 2WW referral of patients with haematuria.