Haematuria assessment — KFP-style written assessment

KFP 1 (10 marks)

A 63-year-old male smoker of 40 pack-years reports one episode of pink urine two weeks ago. No pain. Urine culture at the time grew E. coli; he completed trimethoprim. He mentions the urine looked 'normal' after treatment.^[3]

1. Does the treated infection close this episode? Answer precisely. (4) ^[3]
2. What does his smoking history contribute to risk stratification? (3) ^[6]
3. Outline the referral workup he should expect. (3) ^{[10] [4]}

Model answers

1. No — this is the classic trap. Haematuria during a confirmed UTI can be infection-related, but bladder cancer frequently presents as recurrent 'UTIs', and a single clear post-treatment dipstick does not cancel the risk. In Price's primary-care case-control study non-visible haematuria carried an adjusted OR of 20 (CI 12-33) for bladder cancer; a visible episode in a 60-plus smoker warrants urological workup even when an intervening infection was proven and treated. Repeat urinalysis now; if blood persists or recurs, refer on the cancer pathway. ^[3]
2. Smoking is one of the strongest modifiable bladder-cancer risk factors and appears among increased-risk predictors in the Haematuria Cancer Risk Score model alongside visible haematuria, age, male sex and family history — a model achieving AUC 0.86. Forty pack-years places him firmly in the high-risk tier where cancer incidence reached 6.3% in AUA-tiered cohorts versus 0.4% low-risk. ^{[6] [5]}
3. CT urogram for upper-tract assessment plus cystoscopy for the bladder — together they complete urological evaluation. Urinary cytology may be added but only as an adjunct: prospective data show sensitivity 43.5% (specificity 95.7%, NPV 94.9%), so it neither replaces nor gates the pathway. ^{[10] [4]}