Station 38

Leonard Griffiths

Age: 67 years old male

Examiner

Station List
Doctor
Patient
Full Case

Marking Scheme

Data Gathering and Diagnosis

  • Clarify onset, duration, and recurrence of haematuria
  • Ask whether haematuria is painful or painless (painless visible haematuria is more suspicious for malignancy)
  • Ask if the patient has other urinary symptoms such as painful urination (dysuria) or frequency/urgency to rule out potential UTI
  • Ask about other LUTS: nocturia, weak stream, hesitancy, terminal dribbling (suggestive of BPH, prostate cancer or prostatitis)
  • Ask about fever, chills, or rigors (to assess for systemic infection/UTI or prostatitis)
  • Ask about perineal, rectal, suprapubic, or testicular pain (relevant for prostatitis or other pelvic pathology) 
  • Ask about flank pain or abdominal discomfort (keeping renal stones/ UTI in mind) 
  • Ask about recent heavy exercise or trauma (which can possibly cause transient haematuria)
  • Ask about bleeding elsewhere – gums, bruising, nosebleeds (to screen for coagulopathy or thrombocytopenia)
  • Ask about weight loss, appetite, night sweats, lumps/bumps/masses in abdomen (to screen red flags suggesting malignancy)
  • Ask about use of over-the-counter or prescribed medications, especially NSAIDs or anticoagulants
  • Clarify any past urological history: previous haematuria, infections, stones, prostate issues (to identify recurrent or high-risk patients)
  • Take a brief sexual history, including recent partners or unprotected intercourse (relevant for STI risk)
  • Ask about red flag symptoms of anaemia — focusing on three ‘head’ symptoms (light-headedness, dizziness, headache) and three ‘chest’ symptoms (shortness of breath, chest pain, palpitations) — as these may indicate clinically significant anaemia.
  • Explore social history including smoking, alcohol and occupation history, especially exposure to dyes, rubber, aromatic amines, or industrial chemicals (risk factor for bladder cancer)
  • Ask about family history of urological malignancy
  • Explore patient’s ICE. 
  • Give a working diagnosis of unexplained visible haematuria, requiring urgent 2WW referral to urology to rule out cancer. 

Example of explanation to patient​

Mr. Griffiths, thank you for calling today. I can understand how alarming it must have been to see blood in your urine, that’s always unsettling and understandably worrying.

Based on what you’ve told me; there are a few possible causes. Sometimes, blood in the urine can be due to a urine infection, but you don’t have any of the typical symptoms like burning, needing to go frequently, or feeling unwell. Also, the urine test done at the out-of-hours service didn’t show signs of infection. That makes infection less likely, but we’ll still send a sample to the lab just to be thorough.

Another possibility is kidney stones, but again, you haven’t had any of the usual pain we’d expect, so that’s also less likely in your case.

That said, we take any blood in the urine very seriously, especially in someone over the age of 45, even if it only happened once or was just picked up on a simple urine test like the one you had in the out of hours service. When we see blood in the urine without an obvious cause, we always consider more serious conditions, including bladder or kidney cancer.

I want to reassure you, I’m not saying you have cancer, but we do need to rule that out properly. So, I’ll need to refer you urgently to the urology team. That’s the specialist team that looks after the bladder and urinary system. This referral is made under what’s called the ‘two-week wait pathway’, which means they aim to see you within two weeks to carry out further tests, including a scan and possibly a small camera test to look inside the bladder.

I’d really like to see you in person today, if possible. That would allow me to examine your tummy to check for any lumps or tenderness, and also to examine your back passage so I can feel your prostate. That might sound a bit uncomfortable, but it’s a really important check, as prostate issues can also cause blood in the urine.

I’d also like to arrange some blood tests, to check your prostate, your kidney function, look for any signs of infection or inflammation, and to see if there’s any problem with the way your blood clots. Does all of that sound okay?

You mentioned you’re due to travel to Greece tomorrow and will be away for three weeks. Ideally, I’d like to get you seen as soon as possible before you go, is there any chance the trip could be postponed?

If it absolutely can’t be delayed, then I can still send the referral and notify the hospital team of your travel dates and return. They’ll schedule the appointment for as soon as possible after you’re back.

While you’re away, if you notice any visible blood again, start feeling unwell, get pain, or develop any new symptoms, please seek medical help straightaway. I’d also recommend making sure you have appropriate travel health insurance, just in case you do need to see someone while abroad.

And once you’re back, would you like me to book a follow-up appointment for you so we can review the results and plan the next steps together?

Management

  • Offer face-to-face appointment for further assessment- Including examination of abdomen and flanks to check for tenderness or palpable masses, performing digital rectal examination (DRE) to assess prostate size and texture. 
  • Offer repeat urine dipstick to reassess for haematuria and send mid-stream urine (MSU) for microscopy and culture to rule out infection 
  • Offer blood tests: PSA, U+Es, LFTs, CRP, coagulation profile, bone profile
  • Refer under urgent 2-week wait (2WW) pathway to urology due to age >45 with unexplained visible haematuria
  • Explain the need for urgent assessment to rule out serious conditions, including cancer
  • Discuss upcoming travel and ask if it can be postponed to allow timely investigations
  • If travel cannot be delayed, send 2WW referral and inform urology team of travel dates and expected return, to offer appointment as soon as patient returns. 
  • Advise patient to obtain comprehensive travel insurance in case medical care is needed abroad
  • Safety-net: advise to seek urgent medical care if haematuria returns, pain develops, fever occurs, or if he feels unwell while abroad
  • Offer follow-up appointment on return to review test results and referral outcome.

Learning point from this station: ​

Learning Point from This Station

This station addresses the evaluation and management of haematuria in a 67-year-old man — a red flag symptom that requires prompt and structured assessment in primary care.

According to NICE guidelines, patients should be referred via the urgent suspected cancer pathway (2WW) for bladder cancer if they meet any of the following criteria:

  • Aged 45 and over with unexplained visible haematuria and no evidence of urinary tract infection (UTI), or
  • Aged 45 and over with visible haematuria that persists or recurs following successful treatment of UTI, or
  • Aged 60 and over with unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test.

In this case, the patient is over 60 with a history of visible haematuria, no evidence of infection, and no alternative explanation. He therefore meets criteria for an urgent urology referral under the 2WW pathway. Even though the bleeding has stopped, this must not be dismissed, any episode of visible haematuria in this age group warrants further investigation to rule out serious pathology, including malignancy.

Additionally, NICE recommends considering a PSA test and digital rectal examination (DRE) to assess for prostate cancer in men who present with:

  • Lower urinary tract symptoms (e.g. nocturia, hesitancy, frequency),
  • Erectile dysfunction,
  • Or visible haematuria — as in this case.

This station also emphasises the importance of shared decision-making and negotiation based on the patient’s individual circumstances. The patient was planning to travel for three weeks, longer than the expected timeframe for a 2WW referral. It is therefore essential to:

  • Clearly explain the importance and urgency of early investigation,
  • Emphasise that earlier detection could lead to earlier treatment and better outcomes,
  • Support the patient in making an informed decision about their travel,
  • And if travel cannot be postponed, coordinate care proactively by notifying the urology team of the patient’s travel and ensuring they are seen promptly on return.

The station demonstrates the GP’s role in balancing clinical urgency with patient-centred care, offering appropriate safety-netting, maintaining open communication, and ensuring continuity of care even when logistical challenges arise.

Further reading