(presence of red blood cells in urine) in Primary Care

Surgical Threshold Policy Assessment of Haematuria

(presence of red blood cells in urine)

in Primary Care

Definition

Non-Visible Haematuria (NVH): otherwise referred to as invisible, microscopic or dipstick
positive haematuria; is further subdivided into symptomatic and asymptomatic as follows:

Symptomatic Non-Visible Haematuria (s-NVH): symptoms which prompted a health care
professional to deem that a urine dipstick is necessary such as voiding lower urinary tract
symptoms (LUTS); hesitancy; frequency; dysuria; loin pain or supra-pubic pain.

Asymptomatic Non-Visible Haematuria (a-NVH): incidental detection in the absence of
LUTS or upper urinary tract symptoms.

NVH (Non-Visible / Invisible / Microscopic haematuria) is defined as 1+ on dipstick
urinalysis. Trace haematuria is considered negative. Routine microscopy for confirmation
of haematuria is not recommended.

Visible Haematuria (VH): otherwise referred to as macroscopic or gross or frank
haematuria. Urine is coloured pink or red. Symptom reported by patient or as seen by
health professional. Requires consideration of other causes of discoloured urine
(myoglobinuria, haemoglobinuria, beeturia, drug discolouration – rifampicin, doxorubicin).

Significant Haematuria:
a. Any single episode of VH.
b. Any single episode of s-NVH (in absence of UTI or other transient causes).
c. Persistent a-NVH (in absence of UTI or other transient causes like exercise induced

haematuria or myoglobinuria or menstruation or calculi). Persistence is defined as 2 out
of 3 isolated dipsticks positive for NVH.

OPCS Codes:
M45 Diagnostic endoscopic examination of bladder.
M77 Diagnostic endoscopic examination of urethra.

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Policy

A patient with haematuria should not be referred directly for a cystoscopy without following the
assessment pathway given in this policy.
Assessment of Haematuria in Primary Care (see flow chart on page 4)
Non-Visible / Invisible / Microscopic Haematuria (NVH):
1. Exclude urinary tract infection (UTI) and contamination or other transient causes like

exercise induced haematuria or myoglobinuria or menstruation or calculi.
2. UTI with haematuria should be treated appropriately and a dipstick repeated to confirm the

post-treatment absence of haematuria and infection. UTI is most readily excluded by a
negative dipstick result for both leucocytes and nitrites. Note: UTI can be an indication of
significant genito-urinary pathology; approximately 5% of bladder cancers present as
infection; and recurrent or persistent UTI should be further investigated if clinically indicated.
3. For patients with significant haematuria (see definition on page 1) it is important to exclude
renal disease as a cause, particularly in younger patients. Initial investigations:
• Plasma eGFR – reduced GFR is < 60 ml/min.
• Urine for protein:creatinine ratio (PCR) or albumin:creatinine ratio (ACR) – significant

proteinuria is PCR 50 mg/mmol, or ACR 30 mg/mmol.
NB 24-hour urine collections for protein are rarely required. An approximation to the 24-
hour urine protein or albumin excretion (in mg) is obtained by multiplying the ratio (in
mg/mmol) x 10.
• Blood pressure to confirm/exclude age related hypertension.
4. If all these initial investigations are normal:
• If asymptomatic NVH (a-NVH) and less than 40 years of age – monitor in primary care.
A referral to haematuria clinic (urology) should be considered if they have risk factors
for bladder cancer (eg smoking, occupational exposure, history of carcinogen exposure
or cyclophosphamide treatment).
• If a-NVH and between 40-50 years age – routine referral to haematuria clinic.
• If a-NVH and more than 50 years age – urgent referral to haematuria clinic under the 2-
week wait.
• If symptomatic NVH (s-NVH) and less than 50 years age – routine referral to
haematuria clinic.
• If symptomatic NVH (s-NVH) and more than 50 years age – urgent referral to
haematuria clinic under the 2-week wait.
5. If one or more of the initial investigations (eGFR, PCR or ACR) are not normal:
• Refer for nephrology assessment, particularly in those below 40 years of age.

Visible/Macroscopic Haematuria (VH):
1. Patients (of any age) with painless gross haematuria need urgent referral to haematuria

clinic under the 2-week wait.
2. Recurrent and persistent urinary tract infection (UTI) needs referral to haematuria clinic, but

a single symptomatic urinary infection leading to painful haematuria should be treated and
the patient re-evaluated before referral.

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Nephrology Referral:

1. If any of the initial investigations are not normal.
2. Evidence of declining GFR: by > 10 ml/min at any stage within the last 5 years or by > 5

ml/min within the last year.
3. Stage 4 or 5 CKD (chronic kidney disease): eGFR < 30 ml/min.
4. Isolated haematuria (ie in the absence of significant proteinuria) with hypertension in those

aged < 40 years.
5. Visible haematuria coinciding with intercurrent (usually upper respiratory) infection.
If the above criteria are not met, haematuria itself (visible or non-visible) does not require
nephrology referral. Such patients should, however, continue to be monitored in primary care.

Long Term Monitoring of Patients with Haematuria (Visible or Non-Visible) of
Undetermined Aetiology in Primary Care:

Patients not meeting the criteria for referral to urology or nephrology, or who have negative
urological or nephrological investigations, need long term monitoring due to the uncertainty of
the underlying diagnosis.

Patients should be monitored for the development of:

• s-NVH in a patient with a-NVH.
• Voiding LUTS (lower urinary track symptoms).
• Visible haematuria.
• Significant or increasing proteinuria.
• Progressive renal impairment (falling eGFR) [GFR = glomerular filtration rate].
• Hypertension (noting that the development of hypertension in older people may have no

relation to the haematuria and, therefore, not increase the likelihood of underlying
glomerular disease).

Rationale

Non-Visible/Invisible/microscopic haematuria can be an incidental finding that alone is not
necessarily abnormal. Visible/macroscopic haematuria (blood in the urine) may be a sign of
serious underlying disease, including malignancy that warrants a thorough diagnostic
evaluation1.

Urine dipstick on a fresh voided urine sample is considered a sensitive means of detecting the
presence of haematuria. Urine microscopy has a significant false negative rate and is more
labour intensive, and adds little to establishing the diagnosis of haematuria. Positive
haematuria is considered to be 1+ or greater on dipstick. There is no distinction in significance
between non-haemolysed and haemolysed dipstick-positive haematuria; 1+ positive for either
should be considered equally significant.

Urine cytology and PSA (prostate specific antigen) test, if required, should be done in the clinic
and is not required to be done by a GP.

Evidence

Please refer to the Diagnostic Cystoscopy Surgical Threshold Policy Evidence Summary
20072 and the Joint Consensus Statement on the Initial Assessment of Haematuria3.

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Numbers of
people affected

Epidemiological background

Figures 1 and 2 show the variation in admission rates for Cystoscopy by GP practice in
Peterborough PCT and Cambridgeshire PCT.

Figure 1: Peterborough PCT: Crude Admission Rates for Cystoscopy - 2006/07

14Crude rate per 1,000 registered
12 population
10
1
8 2
6 3
4 4
2 5
0 6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28

Practice code

Practice Rate Per 1,000 PCT Rate Per 1,000

Figure 2: Cambridgeshire PCT: Crude Admission Rates for
Cystoscopy - 2006/07

16
14
12
10

8
6
4
2
0

Practice code
Crude rate per 1,000 registered
population

1
2
3
4
65
7
8
9
10
11
1123
1145
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
3365
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
5532
54
55
56
5587
5609
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76

Practice Rate Per 1,000 PCT Rate Per 1,000

Source (Figures 1 & 2): Cambridgeshire PCT Public Health Intelligence Unit, data extracted from ASP
Commissioning Data Warehouse 20 July 2007

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Table: Number of Admissions for Diagnostic Bladder Cystoscopy in the East of England

Between April 2006 and March 2007

Number of Crude Rate per Standardised SAR 95%

Primary Care Trust Patients 1000 Admission Confidence

Admitted Population Rate (SAR) Intervals

ALL 33,727 5.86 97.1 96.1 – 98.1

Bedfordshire PCT 1,911 4.62 77.5 74 – 81

Cambridgeshire PCT 3,451 5.9 98.9 95.6 – 102

East and North Hertfordshire PCT 3,057 5.36 90.5 87.3 – 93.7

Great Yarmouth and Waveney PCT 2,402 10.82 182.1 174.9 – 189.6

Luton PCT 865 4.25 106.2 99.2 – 113.5

Mid Essex PCT 479 1.31 20.6 18.8 – 22.6

Norfolk PCT 6,075 8.3 124.1 121 – 127.2

North East Essex PCT 2,124 6.85 111.3 106.6 – 116.2

Peterborough PCT 1,143 7.01 152.6 143.9 – 162

South East Essex PCT 2,255 6.48 107.4 103 – 111.9

South West Essex PCT 2,625 6.54 119 114.5 – 123.6

Suffolk PCT 2,954 4.96 74.5 71.8 – 77.2

West Essex PCT 1,623 5.92 99.2 94.4 – 104.2

West Hertfordshire PCT 2,763 4.84 79.2 76.3 – 82.3

Source: Dr Foster Practice Based Commissioning Tool, 15 October 2007

Glossary (ref 4)

Cystoscopy: Refers to looking inside the bladder for medical reasons using an instrument called a
cystoscope.
Haematuria: Is the presence of red blood cells in the urine.
Prognostic: In medicine, an indicator of the course of a disease.
Proteinuria: Means the presence of an excess of serum proteins in the urine.
Urinary: The urinary system is the organ system that produces, stores, and eliminates urine.

References

1. Grossfeld GD, Wolf JS, Litwin MS, Hricak H, Shuler CL, Agerter DC and Carroll PR. Asymptomatic
microscopic haematuria in adults: summary of the AUA best practice policy recommendations.
American Family Physician, 2001; 63: (6) 1145 – 1154.

2. Diagnostic Cystoscopy Surgical Threshold Policy Evidence Summary, Cambridgeshire and
Peterborough Public Health Network, September 2007.

3. Renal Association and British Association of Urological Surgeons. Joint Consensus Statement on
the Initial Assessment of Haematuria. July 2008.

4. Black’s Medical Dictionary. 40th Edition. A & C Black. London 2002.

Lead(s) for policy: Dr Christine Macleod, Head of the PH Network

Policy effective from/ December 2008 (Approved by Cambs PCT PEC – 11 June 2008)
developed: (Approved by Pboro PCT PEC – 16 July 2008)

Policy to be reviewed: (Policy amended to reflect clinicians request to clarify section on Visible/Macroscopic
Reference: Haematuria, page 2.)

December 2009

PHN/restricted/ccpf pols &working area/Surg Threshold Pols - Draft and Agreed/agreed/cystoscopy/
HAEMATURIA ASSESSMENT DEC08

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