Bladder-Renal Cancer – Suspected

Nice guidance link: https://www.nice.org.uk/guidance/ng2

Bladder/renal cancer - clinical presentation

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Visible haematuria (VH)Suspicious kidney/ bladder

lesion on imaging (e.g. incidental finding)

Non-visible haematuria (NVH)

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Aged ≥ 60 years and recurrent/persistent

unexplained UTI

Initial investigations - excluding UTI

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Abnormal DRE+/- raised age-specific PSA

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See pathway Prostate Cancer

- Suspected pathwayUTI excluded or

haematuria persists after treatment

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AGE ≥ 45 years and visiblehaematuria without UTI or

persists/ recurs after successful treatment of

UTI

URGENT 2WWreferral for suspected

urology cancer

All other patients withVH, consider non-urgent

referral to urologist/ nephrologist

If aged <40 years refer to a

nephrologist

If aged ≥ 40 years refer to a urologist

Initial investigations - excluding UTI

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UTI - treat and repeat dipstick following

treatmentNo UTI

See pathways UTI in Females

Symptomatic NVH - dysuria

Age ≥60 years Age <60 years

URGENT 2WWreferral for suspected

urology cancer

Asymptomatic NVH

Repeat dipstickClick for

more info

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Persistent aNVH (2/3 samples)

NVH is not persistent

Low risk of cancer

Investigations: FBC, creatinine & eGFR, urine

for ACR or PCR

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Any age & persistent aNVH - no proteinuria &

normal eGFR

Age ≥ 60 years and raisedWBC

URGENT 2WWreferral for suspected

urology cancer

GP to order ultrasoundof kidneys

Non-urgent referralregardless of

ultrasound result

If aged <40years non-urgent referral to a

nephrologist

If aged ≥ 40years non-urgent referral to a

urologist

Significant proteinuria Reduced eGFR

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for patients

URGENT 2WWreferral for suspected

urology cancer

Consider non-urgent referral to urology for

bladder cancer

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Refer to urologyClick for

more info

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No follow-up needed unless patient presents with other

symptoms or re-present

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If proteinuria significant refer to nephrology

(non-urgent)

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Manage and consider referring to nephrology

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See pathway UTI in Males

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Clinical presentation· painless haematuria is the most common presentation

· may also present with:

· dysuria

· increased frequency

· pelvic pain and symptoms related to urinary tract obstruction - may occur in more advanced tumours

· persistent or recurrent urinary tract infections associated with haematuria

· rarely patients will present with symptoms of metastases

Visible haematuria (VH)· VH should be investigated and managed in the same way irrespective of any anticoagulant or antiplatelet medication

· also referred to as 'macroscopic', 'gross', or 'frank' haematuria

· urine that is coloured pink or red - occasionally appearance of 'coca cola' urine in acute glomerulonephritis

· includes symptom reported by patient or seen by healthcare professional

· any single episode of VH is considered significant haematuria

Other causes of urine discoloration:

· exercise induced haematuria

· beeturia

· drug discolouration – rifampicin, doxorubicin

· myoglobinuria – rare

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Non-visible haematuria (NVH)Also called 'microscopic' or 'dipstick positive' haematuria

NVH can be divided into:• symptomatic non-visible haematuria (sNVH):

• occurs in the presence of symptoms, such as LUTS:• hesitancy• frequency• urgency• dysuria

• any single episode of sNVH is considered significant haematuria - UTI and other transient causes must be excluded first

• asymptomatic non-visible haematuria (aNVH):• is an incidental detection of haematuria in the absence of LUTS or upper urinary tract symptoms• persistent aNVH is considered significant haematuria:

• persistent is defined as 2 out of 3 positive urine dipstick results for non-visible haematuria (NVH)• must exclude UTI and transient causes first

Use urine dipstick samples where possible as this is considered a sensitive method of haematuria detection:• samples should be fresh voided urine without preservatives• significant haematuria is 1+ or greater - trace haematuria is not significant• both non-haemolysed and haemolysed dipstick positive haematuria should be considered of equal significance• routine microscopy to confirm dipstick haematuria is not needed• NB: community based urine samples sent for microscopy have a significant false negative rate

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Initial investigations - includes excluding UTI

• exclude transient causes of haematuria, including UTI:

• a diagnosis of UTI may be excluded if urine dipstick is negative for both leucocytes and nitrites

• if urine dipstick is positive for either leucocytes or nitrites the sample must be sent for microscopy and culture – negative pyuria and culture excludes UTI

• urine dipstick should be repeated following treatment of a UTI

• consider a PSA test and a digital rectal examination to assess for prostate cancer in men with visible haematuria

• consider direct access ultrasound scan to assess for endometrial cancer if vaginal bleeding cannot be excluded.

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Abnormal DRE+/- raised age-specific PSA

Suspect prostate cancer if:• DRE abnormal or• Raised age-specific PSA levels (ng/ml):

• Age <50yrs = >2.5• Age 50-59 = >3.0• Age 60-69 = >4.0• Age 70-79 = >5.0• Age >80 = >20.0

Reference: Best Practice Commissioning Pathway: Prostate Cancer, East Midlands Strategic Clinical Networks, 2015.

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UTI excluded or haematuria persists after treatment

If UTI excluded or haematuria persists after treatment conduct any investigations not already performed above plus plasma

creatinine and estimated glomerular filtration rate (eGFR).

Guidelines differ regarding referral for visible haematuria:

• recently published guidelines by NICE recommend urgent referral using a suspected cancer pathway referral for renal and bladder cancer, to be seen within 2 weeks for:

• patients age 45 years and older with:

• unexplained visible haematuria without UTI; or

• visible haematuria that persists or recurs after successful treatment of a UTI

• the 2008 British Association of Urological Surgeons (BAUS) haematuria guidelines recommend referral to urology for all patients with visible haematuria, regardless of age

Some patients younger than age 40 years with cola-coloured urine and an intercurrent infection (usually an upper respiratory tract infection) will have acute glomerulonephritis:

• refer to nephrology if suspected

NB: It is unclear from current guidelines how to optimally monitor patients with recurrent intermittent visible haematuria (VH), who have had negative investigations in secondary care. Expert opinion suggests a pragmatic approach is that such patients should be investigated every 5 years.

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Initial investigations

• urine dipstick:

• haematuria:

• significant haematuria is 1+ or greater

• trace haematuria is not significant and should be considered negative

• proteinuria

Transient causes must be excluded before the presence of significant haematuria can be established:

• UTI:

• a diagnosis of UTI may be excluded if urine dipstick is negative for both leucocytes and nitrites

• if urine dipstick is positive for either leucocytes or nitrites the sample must be sent for microscopy and culture – negative pyuria and culture excludes UTI

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Repeat Dipstick

Asymptomatic non-visible haematuria (aNVH) should be confirmed by a repeat dipstick of the urine:

· persistent aNVH is considered significant haematuria - persistent is defined as 2 out of 3 positive urine dipstick results for nonvisible haematuria (NVH)

Use urine dipstick samples where possible as this is considered a sensitive method of haematuria detection:

· samples should be fresh voided urine without preservatives

· significant haematuria is 1+ or greater - trace haematuria is not significant

· both non-haemolysed and haemolysed dipstick positive haematuria should be considered of equal significance

· routine microscopy to confirm dipstick haematuria is not needed

NB: community based urine samples sent for microscopy have a significant false negative rate

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Investigations: FBC, creatinine & eGFR, urine for ACR or PCR

Full blood count (to exclude raised white cell count as per NICE cancer guidelines)• urine protein: creatinine ratio (PCR) or albumin:creatinine ratio (ACR):

• evaluate the presence of significant proteinuria:• ACR of 30mg/mmol or more; or• PCR 50mg/mmol or more

• plasma creatinine and estimated glomerular filtration rate (eGFR)• DRE in males

Consider:• prostate specific antigen (PSA) testing in male patients, especially if prostate feels abnormal, in the absence of a proven UTI• consider direct access ultrasound scan to assess for endometrial cancer if vaginal bleeding cannot be excluded.

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No UTI

· a diagnosis of UTI may be excluded if urine dipstick is negative for both leucocytes and nitrites· if urine dipstick is positive for either leucocytes or nitrites the sample must be sent for microscopy and culture - negative pyuria and culture excludes UTI

No UTI

· a diagnosis of UTI may be excluded if urine dipstick is negative for both leucocytes and nitrites· if urine dipstick is positive for either leucocytes or nitrites the sample must be sent for microscopy and culture - negative pyuria and culture excludes UTI

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Symptomatic NVH – dysuria

Recently published guidelines by NICE recommend referring urgently for suspected bladder cancer (within 2 weeks) if:· 60 years and older with unexplained non-visible haematuria and either:

· dysuria; or· raised white cell count on a blood test

Symptomatic NVH – dysuria

Recently published guidelines by NICE recommend referring urgently for suspected bladder cancer (within 2 weeks) if:· 60 years and older with unexplained non-visible haematuria and either:

· dysuria; or· raised white cell count on a blood test

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Refer to urology

The 2008 British Association of Urological Surgeons (BAUS) guidelines recommend referral to a urologist for:

· all patients with symptomatic non-visible haematuria (s-NVH), regardless of age

Refer to urology

The 2008 British Association of Urological Surgeons (BAUS) guidelines recommend referral to a urologist for:

· all patients with symptomatic non-visible haematuria (s-NVH), regardless of age

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Persistent aNVH (2/3 samples)

Persistent aNVH is considered significant haematuria - persistent is defined as 2 out of 3 positive urine dipstick results for non-visible haematuria (NVH). These patients should be further investigated

Persistent aNVH (2/3 samples)

Persistent aNVH is considered significant haematuria - persistent is defined as 2 out of 3 positive urine dipstick results for non-visible haematuria (NVH). These patients should be further investigated

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NVH is not persistent

If subsequent two dipstick samples are negative; i.e. only one out of three (the first of three) samples was positive and the subsequent samples were negative

NVH is not persistent

If subsequent two dipstick samples are negative; i.e. only one out of three (the first of three) samples was positive and the subsequent samples were negative

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Any age & persistent aNVH - no proteinuria & normal eGFR

GPs should order:· ultrasound of the kidneys and· refer if aged ≥40 to a urologist or· refer if aged <40 to a nephrologist

Any age & persistent aNVH - no proteinuria & normal eGFR

GPs should order:· ultrasound of the kidneys and· refer if aged ≥40 to a urologist or· refer if aged <40 to a nephrologist

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Significant proteinuria

Evaluate the presence of significant proteinuria:· albumin: creatinine ratio (ACR) of 30mg/mmol or more; or· urine protein: creatinine ratio (PCR) 50mg/mmol or more

Significant proteinuria

Evaluate the presence of significant proteinuria:· albumin: creatinine ratio (ACR) of 30mg/mmol or more; or· urine protein: creatinine ratio (PCR) 50mg/mmol or more

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Manage and consider referring to nephrology

For patients with reduced eGFR manage according to results in the context of patients preferences and co-morbidities

Manage and consider referring to nephrology

For patients with reduced eGFR manage according to results in the context of patients preferences and co-morbidities

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Recommended resources for patients and carers

Action Bladder Cancer UK - http://actionbladdercanceruk.org/

Bladder Cancer from Cancer Research UK - http://www.cancerresearchuk.org/about-cancer/type/bladder-cancer/

Bladder Cancer leaflet - http://patient.info/health/bladder-cancer-leaflet

Bladder Cancer from Macmillan - http://www.macmillan.org.uk/cancerinformation/cancertypes/bladder/bladdercancer.aspx