This case highlights the difficulties that can arise when several different GPs are involved in the assessment of a patient, together with the analysis of the laboratory results.
In this case, matters were further complicated by the fact that the results were returned from the laboratory in a piecemeal way.
Frank or microscopic haematuria with no proven cause is potentially a sign of cancer of the bladder and renal tract and always needs to be taken seriously. This can be really difficult in general practice given the numbers of patients who present with urinary symptoms.
Haematuria can be classified as:
- Symptomatic non-visible haematuria (S-NVH)
- Asymptomatic non-visible haematuria (A-NVH) where there may be incidental detection in absence of symptoms.
The NICE guidance states for all women with visible or nonvisible haematuria: “If infection has been confirmed re-test the urine for blood with a dipstick after completing treatment with an appropriate antibiotic, to detect persistent haematuria. Persistence is defined as two out of three dipsticks positive for blood on separate occasions.
Refer urgently for investigations of suspected urological cancer if:
- Infection is not confirmed on culture.
- Visible haematuria persists after infection has been successfully treated.
- Non-visible haematuria persists after infection has been successfully treated in a person more than 50 years of age.
- Visible or non-visible haematuria is associated with persistent or recurrent urinary tract infection in a woman aged 40 years or older.”
In the case of Mrs S, referral under the two-week rule was indicated when an infection, but the presence of red blood cells, was not confirmed on urine culture. NICE are due to publish their guidance, Diagnosis and management of bladder cancer in February 2015.