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.
Key red flags
Painless visible haematuria requires urgent urinary-tract cancer assessment even if it settles or anticoagulation is present.
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.
Key medicines
Intravesical mitomycinFor eligible non-muscle-invasive bladder cancer, use a single intravesical instillation commonly containing 40 mg mitomycin in the protocol-defined diluent within 24 hours of TURBT, retained for the locally specified period.
Intravesical BCGUse the selected licensed BCG product once weekly for 6 induction instillations, followed by risk-adapted maintenance for up to 1–3 years according to high-risk NMIBC protocol.