HNY Policy and Pathway Repository - York

NVH:	Presence of blood on dipstick testing- score of +1 or greater counted as positive.
Persistent NVH:	Two out of three or more positive urine dips separated in time by 2 weeks and spurious causes excluded, ignore trace readings.
Symptomatic NVH:	As above with voiding lower urinary tract symptoms such as hesitancy, frequency, urgency, dysuria and loin or supra-pubic pain in the absence of a transient cause such as UTI.
Spurious Causes:	Menstruation, Sexual intercourse, Foods – beetroot, blackberries, rhubarb, Rhabdomyolysis, Drugs – doxorubicin, chloroquine, rifampicin, Lead/mercury poisoning, DOACs, Warfarin.
Transient causes:	UTI: (recurrent UTI infections over age 60, are an indication for further investigation, regardless of haematuria, defined as >3 infections) Exercise (march) haematuria: Repeat dipstick at least 3 days after activity to make sure resolved.

• Visible (frank) haematuria (in adult) without UTI.
• Solid swelling in body of testis 
• Palpable renal mass
• Elevated age specific PSA in men with ten year life expectancy
• High PSA (>20ng/ml) in man with clinically malignant prostate or bone pain
• Any suspected penile cancer

Management

Exclude transient and spurious causes of NVH

See flowchart below.

 

Primary Care Monitoring (Annual Assessments)

Annual Review:

• Annual eGFR>60, ACR <30 and normal BP

Re-refer/refer urology if visible haematuria or symptomatic NVH develops.

Refer nephrology if:

• ACR increases >30 or PCR>50
• eGFR decreases to 5ml/min over 1 year or >10ml/min over 5 years)

Patients who have had negative urological investigations who persist with NVH should be discussed with nephrologist via A+G.
 

When to re-refer to Urology:

• Patients undergoing negative investigations for asymptomatic non-visible haematuria only require repeat Urological investigation if subsequently develop symptomatic NVH or visible haematuria
• Patients undergoing negative investigations for symptomatic non-visible haematuria only require repeat Urological investigation if subsequently develop visible haematuria
• Recurrent visible haematuria beyond 6 month mark since previous investigations, suggest re-referral for repeat investigations (haematuria clinic). GP may wish to liaise with initial Urologist.
  • Consider requesting a CT urogram (or speaking to Urologist) if the visible haematuria recurs within 6 months of the initial investigations

Information to include in referral letter

• Evidence that transient or spurious causes of NVH have been excluded
• Relevant past medical / surgical history
• Current regular medication
• BMI / Smoking status

Investigations prior to referral

• BP
• Creatinine, eGFR
• Urine ACR (albumin creatinine ratio)
• FBC, Clotting screen

References

NICE (June 2015) Guideline Suspected Cancer: Recognition & Referral

Urology CKS cancer referral guideline