Visible Haematuria

Painless visible haematuria must be treated as bladder cancer until proven otherwise. NICE NG12 mandates a 2-week wait (2WW) referral for all visible haematuria in patients aged ≥45 years. Triple assessment (flexible cystoscopy + upper tract CT…

NICE NG12 2WW Referral / Triple Assessment

The pathway

1 · Characterise the haematuria

Painful haematuria: suggests stones, infection, or trauma
Painless haematuria: assume malignancy until excluded — most significant red flag
Initial vs terminal: initial suggests urethral/prostatic source; terminal suggests bladder neck/trigone
Clot retention: assess for acute urinary retention from blood clots

2 · NICE NG12 2WW referral criteria

Visible haematuria at any age: 2WW urology referral
Age ≥45 with visible haematuria: mandatory 2WW
Age ≥45 with unexplained non-visible haematuria + dysuria or elevated PSA: consider 2WW
Age ≥60 with recurrent/persistent unexplained UTI + haematuria: 2WW
Anticoagulation does not explain haematuria — always investigate fully

3 · Urine dipstick and MSU

Dipstick: confirms haematuria
MSU for culture: exclude active UTI before referral
Do NOT delay 2WW referral to complete a course of antibiotics — refer simultaneously
Urine cytology: part of triple assessment, not initial work-up

4 · Immediate management: clot retention

If unable to void and bladder distended: acute urinary retention from clots
Insert 3-way catheter (18Fr) for continuous bladder irrigation (CBI) with normal saline
Irrigate until drainage runs clear
Monitor output: ensure drainage volume ≥ input volume
Urology review if irrigation fails to clear

5 · Triple assessment

Flexible cystoscopy: direct visualisation of bladder mucosa — gold standard for bladder cancer
CT urogram: upper tract imaging for transitional cell carcinoma (TCC) of renal pelvis/ureter
Urine cytology: sensitive for high-grade TCC, less so for low-grade
All three components required for complete assessment

6 · Further investigation

Ultrasound kidney: for renal masses, hydronephrosis
MRI: for soft tissue characterisation of renal masses
Cystoscopy under GA + biopsy: if suspicious lesion on flexible cystoscopy
PSA: in men >45 years (prostate cancer can present with haematuria)

7 · Anticoagulation and haematuria

Anticoagulation does NOT cause haematuria — it may unmask an underlying lesion
Always investigate fully regardless of anticoagulant use
Document anticoagulant type and indication
Do not dismiss as 'anticoagulant-related' without complete triple assessment

Drugs

Drug	Dose	Route	Notes
Normal saline (continuous bladder irrigation)	Titrated	Via 3-way catheter	For clot retention. Run fast enough to keep drainage clear. Use 3-litre bags.
Tranexamic acid	Urology decision, not routine	PO	Not a ward-level decision. Risk of clot retention and ureteric obstruction, particularly with upper-tract bleeding. Only on urology advice, after clot retention has been managed.
Tamsulosin	400mcg OD	PO	If BPH contributing to outflow obstruction with haematuria.

When to escalate

Clot retention — 3-way catheter and bladder irrigation urgently,Haematuria causing haemodynamic compromise (Hb <70) — transfuse, cystoscopy ± diathermy,Urothelial malignancy on cystoscopy — urgent MDT referral and staging CT,Synchronous upper and lower tract disease — hepatobiliary/urology MDT

Reference: NICE NG12 Suspected Cancer Recognition and Referral 2015 / BAUS Haematuria Guidelines 2020

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