Intended for healthcare professionals

Practice Rational Testing

Investigating asymptomatic invisible haematuria

BMJ 2014; 349 doi: (Published 17 November 2014) Cite this as: BMJ 2014;349:g6768
  1. Barnaby Hole, specialist trainee1,
  2. Tim Whittlestone, clinical director and consultant urologist2,
  3. Charles Tomson, consultant nephrologist1
  1. 1Department of Renal Medicine, Southmead Hospital, Bristol BS10 5NB, UK
  2. 2Department of Urology, Southmead Hospital, Bristol, UK,
  1. Correspondence to: C Tomson charles.tomson{at}

The bottom line

  • When invisible haematuria is detected ask the patient about urinary tract symptoms

  • Regard two out of three positive dipstick tests as confirmation of persistent invisible haematuria

  • Visible haematuria is associated with cancer in 8-25% of cases, but invisible haematuria in only 2.6%. Fewer than 0.5% of people investigated for asymptomatic invisible haematuria aged under 50 years have cancer

  • A focused history and examination, estimated glomerular filtration rate, and urinary albumin:creatinine ratio inform further management. Proteinuria and loss of excretory renal function are associated with greater risk of progressive kidney disease—a nephrology opinion is warranted in such cases. Many patients do not need a biopsy and can be monitored in the community

  • Current UK and US guidelines advocate urological referral to exclude cancer in smokers and people over 35-40 years of age, but patients should be made aware that fewer than 3% of investigated cases have cancer

Urine dipstick testing shows 1+ haematuria in a 42 year old man registering as a new patient with a general practice. No proteinuria is detected. He has never seen blood in his urine, has no lower urinary tract symptoms, no symptoms to suggest kidney stones, and no systemic symptoms. He is an ex-smoker with no relevant medical, occupational, or family history, and he takes no prescribed or over the counter drugs or supplements. His blood pressure is 136/88 mm Hg. Physical examination is unremarkable. Serum creatinine is 95 μmol/L, giving an estimated glomerular filtration rate of 80 mL/min/1.73m2.

What is the next investigation?

The convenience of multistix testing has resulted in inadvertent screening for asymptomatic invisible haematuria. Population screening is considered justified in Japan,1 but no other country has a national programme, because the risks and costs outweigh any potential benefit. Once asymptomatic invisible haematuria is detected, guidelines in the United Kingdom and United States recommend …

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