Ep 20 - Management of non-visible haematuria (microscopic haematuria) in primary care

In this episode, Kevin looks at common questions around non-visible haematuria (NVH) – the condition formerly known as microscopic haematuria. Should we be screening for NVH? What follow-up investigations should we do for people with asymptomatic NVH? Should we change our approach for patients taking aspirin, warfarin or direct-acting oral anticoagulants (DOACs)? Finally, who should we refer and how urgently?

Key references and resources discussed in the episode:

• Renal Association and British Association of Urological Surgeons. Joint Consensus Statement on the Initial Assessment of Haematuria.
• Hole B, Whittlestone T, Tomson C. Investigating asymptomatic invisible haematuria. BMJ. 2014;349:g6768.
• NICE. Suspected cancer: recognition and referral. NICE guideline NG12. 2015.
• NHS Scotland. Scottish referral guidelines for suspected cancer. Urological cancers. 2019

Key take-home points from the episode:

1. There is no compelling evidence to support population screening for NVH in asymptomatic people.
2. All those with persistent NVH require primary care follow-up to exclude progressive kidney disease.
   • Persistent is defined as asymptomatic NVH that persists for at least two out of three samples, separated by 2–3 weeks.
   • Assess baseline renal status: blood pressure, urea and electrolytes and urinary albumin to creatinine ratio.
   • Individuals on aspirin, warfarin or DOACs should be managed in the same way as those not on these drugs.
3. Those <40 years with persistent NVH and normal baseline renal function need annual primary care monitoring for as long as the NVH persists (until two negative urinalyses).
   • Refer to renal if estimated glomerular filtration rate (eGFR) is <30 mL/min/1.73 m2 on two separate occasions or eGFR falls by >5 mL/min/1.73 m2 over 1 year or >10 mL/min/1.73 m2 over 5 years or the person develops proteinuria.
4. Those ≥40 years require referral to urology.
   • NICE 2015 suspected cancer guideline suggests an urgent 2 week wait referral for bladder cancer if the person is ≥60 years and has unexplained NVH and either dysuria or a raised white cell count.
   • Scottish 2019 cancer guidance suggests:
     • An urgent suspicion of cancer referral for those ≥60 years with unexplained NVH and either dysuria or a raised white cell count.
     • Routine referral for all those with asymptomatic persistent NVH without obvious cause.