Synopsis
Investigate visible haematuria with cystoscopy and upper-tract imaging, obtain muscle-containing TURBT pathology, risk-stratify non-muscle-invasive disease and coordinate intravesical, radical, organ-preserving and systemic treatment.
- Visible haematuria is a pivotal clue in Bladder and upper-tract urothelial cancer: Intermittent painless red urine is the classic presentation; a single episode deserves investigation despite anticoagulation or a presumed infection.
- Immediate priority in unstable Bladder and upper-tract urothelial cancer: Resuscitate, check haemoglobin and coagulation, obtain large-bore three-way catheter irrigation for clot retention with urgent urology, and decompress an infected obstructed upper tract by stent or nephrostomy alongside antibiotics.
- Flexible cystoscopy is used early to inspect the bladder directly in haematuria assessment and identify lesions for resection. A normal cystoscopy does not evaluate the upper tracts; flat carcinoma in situ may be subtle and needs cytology or directed biopsy when suspected.
- CT urography refines the next decision because use an appropriate contrast and excretory protocol; ultrasound may be chosen first in selected low-risk or contrast-limited settings but is less sensitive for urothelial lesions.
- Examine bladder and upper tracts: Confirm urinalysis, culture when infection is plausible, renal function and blood count, but do not dismiss visible haematuria because anticoagulation is present.
- Risk-stratify after high-quality TURBT: Use immediate intravesical mitomycin for eligible low- or intermediate-risk disease when perforation and significant bleeding are absent.
- A major avoidable harm is clot retention and haemorrhage; Heavy bleeding causes painful obstruction, anaemia and transfusion or endoscopic haemostasis need.
- A common diagnostic trap is urinary infection: Dysuria and haematuria can arise from infection, but visible blood that persists or recurs after treatment still needs cancer assessment.
Key red flags
Painless visible haematuria requires urgent urinary-tract cancer assessment even if it settles or anticoagulation is present.
Clots, suprapubic pain and inability to void suggest clot retention.
Flank pain, fever and hydronephrosis suggests infected upper-tract obstruction.
Persistent irritative urinary symptoms with sterile cultures may reflect carcinoma in situ.
Hydronephrosis, pelvic pain, weight loss or renal impairment suggests invasive or upper-tract disease.
A high-grade T1 tumour lacks detrusor muscle in the first TURBT specimen and may be understaged.
Painful inability to void with heavy haematuria requires urgent catheter, irrigation and endoscopic haemostasis assessment.
Investigation priorities
Inspect the bladder directly in haematuria assessment and identify lesions for resection.
Management branches
Visible haematuria or qualifying persistent non-visible haematuria prompts suspected urothelial cancer assessment.
- Confirm urinalysis, culture when infection is plausible, renal function and blood count, but do not dismiss visible haematuria because anticoagulation is present.
- Perform flexible cystoscopy and appropriate upper-tract imaging, usually CT urography, through the urgent pathway.
- Resect or biopsy identified lesions and complete an independent renal or prostate work-up when anatomy indicates another primary.