Painless visible haematuria — evaluation pathway and the glomerular vs urological distinction

Diagnosis: painless visible haematuria — urological pattern; cancer until proven otherwise. The combination of painless visible bleeding, isomorphic (intact, non-dysmorphic) red cells, and the absence of casts and proteinuria localises the source to the urological tract (bladder, upper tract or prostate).^[1]

The cardinal rule. Painless visible haematuria in an adult is malignancy until proven otherwise — most commonly bladder cancer, then renal-cell carcinoma and upper-tract urothelial tumour. The smoking history and age raise the pre-test probability substantially.^[1]

The pivotal distinction — glomerular vs urological (settled by urine microscopy):

• Glomerular = dysmorphic RBCs (acanthocytes >5%), red-cell casts, proteinuria, brown/cola urine → nephrology work-up (UACR, complement, ANA/ANCA, renal biopsy).
• Urological = isomorphic (intact) RBCs, no casts, little/no proteinuria → urology work-up (CT urogram + cystoscopy).^[1]

This patient's microscopy confirms the urological branch.

Anticoagulant caveat. Warfarin AMPLIFIES bleeding but does NOT cause haematuria de novo — the underlying cause (often cancer) must still be excluded in parallel with reversing the anticoagulant if clinically indicated. A therapeutic INR is never an acceptable sole explanation.

Stepwise investigation:

1. Confirm and exclude transient causes — repeat urinalysis; exclude infection (urine culture), heavy exercise, trauma (he has none; his warfarin is recognised but is not the cause).
2. First-line bloods — U&E and eGFR, FBC (anaemia from chronic bleeding), coagulation/INR, UACR, blood pressure.
3. Urology work-up — both mandatory:
   • CT urogram (CT abdomen/pelvis with excretory phase) — the gold standard for the upper tract: visualises renal masses, upper-tract urothelial tumours (filling defects) and stones. Check eGFR before contrast (contrast-nephropathy risk).^[3]
   • Cystoscopy — the gold standard for the bladder: directly visualises, biopsies and resects a bladder lesion (TURBT for bladder cancer).
4. Urine cytology — high sensitivity for high-grade tumours and carcinoma in situ; useful as an adjunct in this high-risk patient.

Definitive management by cause (after diagnosis): bladder cancer → TURBT ± intravesical BCG or radical cystectomy by stage; renal-cell carcinoma → partial/radical nephrectomy; BPH (only after cancer excluded) → alpha-blocker (tamsulosin 0.4 mg PO daily) ± 5-ARI (finasteride 5 mg PO daily), TURP for refractory disease.

Disposition: urgent suspected-cancer referral (within 2 weeks per NICE NG12) for cystoscopy + CT urogram. Do not delay for infection treatment if cancer is the leading concern — investigate in parallel.