A single episode of visible (macroscopic) haematuria in an adult warrants urological referral and investigation for urothelial cancer, not a course of antibiotics and reassurance. The bleeding is often painless and intermittent, and waiting for it to recur wastes the window in which the tumour is most treatable.
Investigation means cystoscopy plus upper-tract imaging — a CT urogram where available — because a normal ultrasound or a treated urine infection does not exclude a bladder or upper-tract tumour. Confirm that any attributed urinary infection has actually resolved and that the haematuria has cleared with it.
Smoking is the dominant modifiable risk, with occupational exposures (dyes, rubber, solvents) adding to it. In a smoker or an older adult, the threshold to refer visible haematuria should be especially low.
- Refer any adult with visible haematuria for cystoscopy and upper-tract imaging, even after one episode.
- Do not attribute visible haematuria to a urine infection without confirming it clears with treatment.
- A normal ultrasound does not exclude a urothelial tumour — image the upper tracts and scope the bladder.
- Lower the threshold further in smokers and those with occupational dye or solvent exposure.
Why it matters
Painless visible haematuria is the classic, easily-dismissed presentation of a bladder cancer that is curable when caught early.
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