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 noticing dark red blood in his urine throughout the stream on several occasions. He denies dysuria, urinary frequency, urgency, fever, or flank pain. He has a 40 pack-year smoking history and worked for many years in an industrial dye factory. On physical examination, his abdomen is soft and non-tender with no palpable masses or costovertebral angle tenderness. Digital rectal examination reveals a smooth, non-tender, moderately enlarged prostate gland with no discrete nodules. Urinalysis shows 3+ blood, negative nitrites, and negative leucocytes.
Vital signs
- HR
- 76 bpm
- BP
- 132/84 mmHg
- RR
- 16/min
- Temp
- 36.8 °C
- SpO₂
- 98%
Examination findings
- Abdomen soft, non-tender, no palpable masses
- No costovertebral angle tenderness
- Digital rectal exam: smooth, non-tender, moderately enlarged prostate without nodules
Investigations
| Haemoglobin | 13.8 g/dL | reference: 13.5-17.5 |
| White cell count | 6.8 10^9/L | reference: 4.0-11.0 |
| Serum creatinine | 88 µmol/L | reference: 60-110 |
| eGFR | >90 mL/min/1.73m2 | reference: >90 |
Question 1 of 3
What is the most likely diagnosis?
Painless macroscopic (visible) haematuria in a patient over 45 years of age, particularly with risk factors such as cigarette smoking and aromatic amine exposure (dye factory), is bladder carcinoma until proven otherwise. Acute pyelonephritis would present with fever, systemic upset, flank pain, and positive nitrites/leucocytes on urinalysis. Benign prostatic hyperplasia can cause haematuria but typically presents with lower urinary tract symptoms (LUTS) and is a diagnosis of exclusion after ruling out malignancy. Renal calculi present with severe episodic renal colic and microscopic or macroscopic haematuria.
Teaching point: Painless visible haematuria in an adult aged 45 or over is considered a red flag for urological malignancy (most commonly bladder cancer) until proven otherwise.
Question 2 of 3
Which of the following is the most appropriate next step in investigation for this patient?
According to UK national guidelines (NICE), patients aged 45 and over with unexplained visible haematuria (without UTI or persisting after UTI treatment) require urgent two-week wait referral for flexible cystoscopy and upper tract imaging (renal ultrasound or CT urogram) to evaluate for urothelial cancer. Urine culture is unnecessary here as urinalysis shows no signs of infection (negative leucocytes/nitrites) and the patient lacks dysuria. Non-contrast CT KUB is used to investigate renal stones, not urothelial lesions. A PSA may be considered later but should not delay urgent cancer pathway investigation.
Teaching point: Unexplained painless visible haematuria in patients aged ≥45 requires urgent 2-week wait referral for flexible cystoscopy and upper tract imaging.
Question 3 of 3
Two days later, while awaiting his outpatient urology appointment, the patient presents to the emergency department unable to void for 8 hours, in severe suprapubic pain, with dark red blood and visible blood clots at his urethral meatus. What is the single most appropriate immediate management step?
The patient has developed acute urinary retention secondary to blood clots (clot retention). The correct immediate management is the insertion of a large-bore (e.g., 20-24Fr) 3-way Foley catheter to perform manual bladder washout of clots, followed by continuous bladder irrigation with normal saline to prevent re-clotting. A standard 14Fr 2-way catheter is too narrow and will quickly become obstructed by blood clots. Emergency cystoscopy is indicated if catheter insertion and manual washout fail. Loop diuretics like furosemide will increase urine output but will not relieve an obstructed bladder neck caused by clots.
Teaching point: Clot retention requires immediate insertion of a large-bore 3-way catheter, manual clot washout, and continuous bladder irrigation.
Key learning points
- Painless visible haematuria in patients aged ≥45 years must be treated as a suspected urological malignancy until proven otherwise.
- Smoking and occupational exposure to aromatic amines (e.g., in dye, rubber, or leather manufacturing) are major risk factors for transitional cell carcinoma of the bladder.
- Acute clot retention requires urgent bladder decompression using a large-bore 3-way urinary catheter with manual washout and continuous saline irrigation.
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