Renal and urology · Moderate
This case is fictional and exists for study. It describes no real patient.
62 years · male
A 62-year-old male presents to his general practitioner with a 3-week history of painless, visible haematuria. He reports passing dark red urine intermittently without any associated dysuria, urinary frequency, urgency, or fever. He has a 40 pack-year history of cigarette smoking but takes no regular medications. On examination, his abdomen is soft and non-tender with no palpable masses or suprapubic tenderness. Digital rectal examination reveals a smooth, non-tender prostate of normal size. Urine dipstick shows 3+ blood, negative leucocytes, and negative nitrites. Laboratory evaluation shows normal renal function and full blood count.
Vital signs
- HR
- 76 bpm
- BP
- 132/84 mmHg
- RR
- 14/min
- Temp
- 36.8 °C
- SpO₂
- 98%
Examination findings
- Abdomen soft and non-tender
- No flank or suprapubic tenderness
- Prostate normal size, smooth, and non-tender on DRE
Investigations
| Haemoglobin | 13.8 g/dL | reference: 13.0-17.0 |
| Serum Creatinine | 85 µmol/L | reference: 60-110 |
| eGFR | >90 mL/min/1.73m² | reference: >90 |
| Urine Dipstick Blood | 3+ | reference: Negative |
| Urine Microscopy RBCs | >50 non-dysmorphic RBCs/hpf | reference: 0-3 |
Question 1 of 3
Which of the following is the most likely underlying diagnosis?
Painless visible haematuria in a patient over 45 years of age, especially with a significant smoking history, is the classic presentation of transitional cell carcinoma of the bladder. Acute urinary tract infection typically presents with dysuria, frequency, and positive nitrites/leucocytes on dipstick. Benign prostatic hyperplasia usually presents with lower urinary tract symptoms (LUTS) like hesitancy and weak stream rather than isolated gross haematuria. IgA nephropathy typically affects younger adults and presents with visible haematuria following an upper respiratory infection, often accompanied by dysmorphic RBCs or red cell casts.
Teaching point: Painless visible haematuria in a patient aged 45 or older should be considered bladder or upper tract urological cancer until proven otherwise.
Question 2 of 3
What is the single most appropriate next step in management?
According to NICE guidelines (NG12), adults aged 45 and over with unexplained visible haematuria without urinary tract infection should be referred urgently via the 2-week wait (2WW) cancer pathway for investigation, which includes flexible cystoscopy and upper tract imaging (e.g., CT urography or ultrasound). Empirical antibiotics are inappropriate given the absence of infective symptoms and negative dipstick for leucocytes/nitrites. A non-contrast CT KUB is the investigation of choice for renal colic (stones), not urological cancer. Delaying evaluation by rechecking in 4 weeks risks delayed cancer diagnosis.
Teaching point: NICE guidelines mandate an urgent 2-week wait referral for flexible cystoscopy in patients aged 45+ with unexplained visible haematuria.
Question 3 of 3
Which finding best distinguishes a lower urinary tract (extra-glomerular) cause of haematuria from a glomerular cause in this patient?
Non-dysmorphic (isomorphic) red blood cells and the absence of red cell casts or significant proteinuria strongly indicate a non-glomerular/lower urinary tract source (such as bladder, ureter, or kidney lesions). Glomerular causes typically produce dysmorphic red cells, red cell casts, and proteinuria. Dipstick blood positivity occurs equally in both glomerular and extra-glomerular bleeding. Smoking is an important epidemiological risk factor for bladder cancer, but it is not a laboratory finding that differentiates the anatomical source of red cells. Normal eGFR can be present in both early glomerular disease and urological lesions.
Teaching point: Non-dysmorphic red cells without red cell casts or proteinuria point toward an extra-glomerular (urological) origin of haematuria.
Key learning points
- Painless visible haematuria in patients aged 45 and older is a classic red-flag symptom for urological malignancy.
- NICE guidelines specify an urgent 2-week wait referral for cystoscopy and upper tract imaging for patients aged 45+ with unexplained gross haematuria.
- Non-dysmorphic RBCs on urine microscopy suggest extra-glomerular bleeding, whereas dysmorphic RBCs and red cell casts indicate a glomerular origin.
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