A single episode of visible (macroscopic) haematuria without pain is the classic presentation of urothelial cancer, and it warrants prompt urological referral every time, not a wait-and-see course of antibiotics.
Refer on the first episode, even if it clears, and even if a urine dip later turns negative. Standard work-up is cystoscopy plus upper-tract imaging — CT urography where available — because a normal ultrasound does not exclude a bladder tumour. Ask about smoking and occupational exposures, which raise the pretest probability.
Do not let a presumed urinary tract infection or anticoagulation explain away visible haematuria without first excluding malignancy. Microscopic haematuria is lower risk but still merits assessment by risk; visible haematuria is the one that must not be missed.
- Refer any visible painless haematuria urgently, even a single episode that clears.
- Work up with cystoscopy and upper-tract imaging; a normal ultrasound does not exclude a tumour.
- Do not attribute visible haematuria to infection or anticoagulation without excluding cancer first.
- Ask about smoking and occupational exposures, which raise the risk of urothelial cancer.
Why it matters
Visible painless haematuria is the hallmark of urothelial cancer, and attributing it to infection or anticoagulation delays a diagnosis that is curable when caught early.
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