Assessment of Haematuria (presence of red blood cells in urine) in Primary Care Surgical Threshold Policy Definition Non-Visible Haematuria (NVH): otherwise referred to as invisible, microscopic or dipstick positive haematuria; is further subdivided into symptomatic and asymptomatic as follows: Symptomatic Non-Visible Haematuria (s-nvh): symptoms which prompted a health care professional to deem that a urine dipstick is necessary such as voiding lower urinary tract symptoms (LUTS); hesitancy; frequency; dysuria; loin pain or supra-pubic pain. Asymptomatic Non-Visible Haematuria (a-nvh): incidental detection in the absence of LUTS or upper urinary tract symptoms. NVH (Non-Visible / Invisible / Microscopic haematuria) is defined as 1+ on dipstick urinalysis. Trace haematuria is considered negative. Routine microscopy for confirmation of haematuria is not recommended. Visible Haematuria (VH): otherwise referred to as macroscopic or gross or frank haematuria. Urine is coloured pink or red. Symptom reported by patient or as seen by health professional. Requires consideration of other causes of discoloured urine (myoglobinuria, haemoglobinuria, beeturia, drug discolouration rifampicin, doxorubicin). Significant Haematuria: a. Any single episode of VH. b. Any single episode of s-nvh (in absence of UTI or other transient causes). c. Persistent a-nvh (in absence of UTI or other transient causes like exercise induced haematuria or myoglobinuria or menstruation or calculi). Persistence is defined as 2 out of 3 isolated dipsticks positive for NVH. OPCS Codes: M45 Diagnostic endoscopic examination of bladder. M77 Diagnostic endoscopic examination of urethra. Page 1 of 6
Policy A patient with haematuria should not be referred directly for a cystoscopy without following the assessment pathway given in this policy. Assessment of Haematuria in Primary Care (see flow chart on page 4) Non-Visible / Invisible / Microscopic Haematuria (NVH): 1. Exclude urinary tract infection (UTI) and contamination or other transient causes like exercise induced haematuria or myoglobinuria or menstruation or calculi. 2. UTI with haematuria should be treated appropriately and a dipstick repeated to confirm the post-treatment absence of haematuria and infection. UTI is most readily excluded by a negative dipstick result for both leucocytes and nitrites. Note: UTI can be an indication of significant genito-urinary pathology; approximately 5% of bladder cancers present as infection; and recurrent or persistent UTI should be further investigated if clinically indicated. 3. For patients with significant haematuria (see definition on page 1) it is important to exclude renal disease as a cause, particularly in younger patients. Initial investigations: Plasma egfr reduced GFR is < 60 ml/min. Urine for protein:creatinine ratio (PCR) or albumin:creatinine ratio (ACR) significant proteinuria is PCR 50 mg/mmol, or ACR 30 mg/mmol. NB 24-hour urine collections for protein are rarely required. An approximation to the 24- hour urine protein or albumin excretion (in mg) is obtained by multiplying the ratio (in mg/mmol) x 10. Blood pressure to confirm/exclude age related hypertension. 4. If all these initial investigations are normal: If asymptomatic NVH (a-nvh) and less than 40 years of age monitor in primary care. A referral to haematuria clinic (urology) should be considered if they have risk factors for bladder cancer (eg smoking, occupational exposure, history of carcinogen exposure or cyclophosphamide treatment). If a-nvh and between 40-50 years age routine referral to haematuria clinic. If a-nvh and more than 50 years age urgent referral to haematuria clinic under the 2- week wait. If symptomatic NVH (s-nvh) and less than 50 years age routine referral to haematuria clinic. If symptomatic NVH (s-nvh) and more than 50 years age urgent referral to haematuria clinic under the 2-week wait. 5. If one or more of the initial investigations (egfr, PCR or ACR) are not normal: Refer for nephrology assessment, particularly in those below 40 years of age. Visible/Macroscopic Haematuria (VH): 1. Patients (of any age) with painless gross haematuria need urgent referral to haematuria clinic under the 2-week wait. 2. Recurrent and persistent urinary tract infection (UTI) needs referral to haematuria clinic, but a single symptomatic urinary infection leading to painful haematuria should be treated and the patient re-evaluated before referral. Page 2 of 6
Nephrology Referral: 1. If any of the initial investigations are not normal. 2. Evidence of declining GFR: by > 10 ml/min at any stage within the last 5 years or by > 5 ml/min within the last year. 3. Stage 4 or 5 CKD (chronic kidney disease): egfr < 30 ml/min. 4. Isolated haematuria (ie in the absence of significant proteinuria) with hypertension in those aged < 40 years. 5. Visible haematuria coinciding with intercurrent (usually upper respiratory) infection. If the above criteria are not met, haematuria itself (visible or non-visible) does not require nephrology referral. Such patients should, however, continue to be monitored in primary care. Long Term Monitoring of Patients with Haematuria (Visible or Non-Visible) of Undetermined Aetiology in Primary Care: Patients not meeting the criteria for referral to urology or nephrology, or who have negative urological or nephrological investigations, need long term monitoring due to the uncertainty of the underlying diagnosis. Patients should be monitored for the development of: s-nvh in a patient with a-nvh. Voiding LUTS (lower urinary track symptoms). Visible haematuria. Significant or increasing proteinuria. Progressive renal impairment (falling egfr) [GFR = glomerular filtration rate]. Hypertension (noting that the development of hypertension in older people may have no relation to the haematuria and, therefore, not increase the likelihood of underlying glomerular disease). Rationale Non-Visible/Invisible/microscopic haematuria can be an incidental finding that alone is not necessarily abnormal. Visible/macroscopic haematuria (blood in the urine) may be a sign of serious underlying disease, including malignancy that warrants a thorough diagnostic evaluation 1. Urine dipstick on a fresh voided urine sample is considered a sensitive means of detecting the presence of haematuria. Urine microscopy has a significant false negative rate and is more labour intensive, and adds little to establishing the diagnosis of haematuria. Positive haematuria is considered to be 1+ or greater on dipstick. There is no distinction in significance between non-haemolysed and haemolysed dipstick-positive haematuria; 1+ positive for either should be considered equally significant. Urine cytology and PSA (prostate specific antigen) test, if required, should be done in the clinic and is not required to be done by a GP. Please refer to the Diagnostic Cystoscopy Surgical Threshold Policy Evidence Summary 2007 2 and the Joint Consensus Statement on the Initial Assessment of Haematuria 3. Evidence Page 3 of 6
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Numbers of people affected Epidemiological background Figures 1 and 2 show the variation in admission rates for Cystoscopy by GP practice in Peterborough PCT and Cambridgeshire PCT. Figure 1: Peterborough PCT: Crude Admission Rates for Cystoscopy - 2006/07 14 Crude rate per 1,000 registered population 12 10 8 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Practice code Practice Rate Per 1,000 PCT Rate Per 1,000 Figure 2: Cambridgeshire PCT: Crude Admission Rates for Cystoscopy - 2006/07 Crude rate per 1,000 registered population 16 14 12 10 8 6 4 2 0 1 23 4 56 7 89 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 Practice code Practice Rate Per 1,000 PCT Rate Per 1,000 Source (Figures 1 & 2): Cambridgeshire PCT Public Health Intelligence Unit, data extracted from ASP Commissioning Data Warehouse 20 July 2007 Page 5 of 6
Table: Number of Admissions for Diagnostic Bladder Cystoscopy in the East of England Between April 2006 and March 2007 Number of Crude Rate per Standardised SAR 95% Primary Care Trust Patients Admitted 1000 Population Admission Rate (SAR) Confidence Intervals ALL 33,727 5.86 97.1 96.1 98.1 Bedfordshire PCT 1,911 4.62 77.5 74 81 Cambridgeshire PCT 3,451 5.9 98.9 95.6 102 East and North Hertfordshire PCT 3,057 5.36 90.5 87.3 93.7 Great Yarmouth and Waveney PCT 2,402 10.82 182.1 174.9 189.6 Luton PCT 865 4.25 106.2 99.2 113.5 Mid Essex PCT 479 1.31 20.6 18.8 22.6 Norfolk PCT 6,075 8.3 124.1 121 127.2 North East Essex PCT 2,124 6.85 111.3 106.6 116.2 Peterborough PCT 1,143 7.01 152.6 143.9 162 South East Essex PCT 2,255 6.48 107.4 103 111.9 South West Essex PCT 2,625 6.54 119 114.5 123.6 Suffolk PCT 2,954 4.96 74.5 71.8 77.2 West Essex PCT 1,623 5.92 99.2 94.4 104.2 West Hertfordshire PCT 2,763 4.84 79.2 76.3 82.3 Source: Dr Foster Practice Based Commissioning Tool, 15 October 2007 Cystoscopy: Haematuria: Prognostic: Proteinuria: Urinary: Glossary (ref 4) Refers to looking inside the bladder for medical reasons using an instrument called a cystoscope. Is the presence of red blood cells in the urine. In medicine, an indicator of the course of a disease. Means the presence of an excess of serum proteins in the urine. The urinary system is the organ system that produces, stores, and eliminates urine. References 1. Grossfeld GD, Wolf JS, Litwin MS, Hricak H, Shuler CL, Agerter DC and Carroll PR. Asymptomatic microscopic haematuria in adults: summary of the AUA best practice policy recommendations. American Family Physician, 2001; 63: (6) 1145 1154. 2. Diagnostic Cystoscopy Surgical Threshold Policy Evidence Summary, Cambridgeshire and Peterborough Public Health Network, September 2007. 3. Renal Association and British Association of Urological Surgeons. Joint Consensus Statement on the Initial Assessment of Haematuria. July 2008. 4. Black s Medical Dictionary. 40 th Edition. A & C Black. London 2002. Lead(s) for policy: Dr Christine Macleod, Head of the PH Network December 2008 (Approved by Cambs PCT PEC 11 June 2008) Policy effective from/ (Approved by Pboro PCT PEC 16 July 2008) developed: (Policy amended to reflect clinicians request to clarify section on Visible/Macroscopic Haematuria, page 2.) Policy to be reviewed: December 2009 PHN/restricted/ccpf pols &working area/surg Threshold Pols - Draft and Agreed/agreed/cystoscopy/ Reference: HAEMATURIA ASSESSMENT DEC08 Page 6 of 6