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Health condition · Clinically reviewed

Haematuria, blood in urine - the NICE pathway, and what happens next.

Visible or non-visible, blood in urine always needs a clinical answer. Flexible cystoscopy and CT urogram do most of the diagnostic work, and management follows the underlying cause.

Also see our full clinical guide at /conditions/haematuria/.

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Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against NICE, BAUS and peer-reviewed sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK guidance including the NICE NG12 two-week wait bladder cancer pathway.

Key facts

Haematuria at a glance.

The essentials, in plain English - what it is, where it comes from, and how it is investigated in the UK today.

  • What it is

    Blood in the urine, either visible (frank) or non-visible (microscopic) - always warrants a clinical explanation, never dismissed.

  • Visible haematuria

    Pink, red or tea-coloured urine seen with the naked eye - the highest-risk presentation for urological cancer.

  • Non-visible

    Blood detected on dipstick or microscopy only - persistent findings still need urology or nephrology review.

  • Where it comes from

    Kidneys, ureters, bladder, prostate or urethra - and sometimes systemic bleeding or clotting causes.

  • NICE 2WW pathway

    NG12 urgent referral for adults 45+ with unexplained visible haematuria, or 60+ with non-visible plus dysuria or raised WCC.

  • Core investigations

    Flexible cystoscopy and CT urogram are the workhorses - imaging the upper tract and inspecting the bladder directly.

Why this guide matters

Every episode deserves an answer.

Haematuria is a symptom, not a diagnosis. The three points below shape the whole pathway - and why the workup matters.

  • Visible haematuria is a red flag

    In adults over 45, painless visible haematuria is bladder cancer until proven otherwise - NICE NG12 mandates urgent referral.

  • The tract has four levels

    Kidney, ureter, bladder and urethra each have their own differentials - imaging plus cystoscopy covers all four in one workup.

  • Kidney disease can hide here

    Non-visible haematuria with proteinuria may be glomerular - a nephrology, not urology, problem.

How the diagnosis is made

From first dipstick to a clear diagnosis.

The steps a UK GP, urologist or nephrologist will normally follow, in order - so you know what to expect and why.

  1. 01

    Assessing

    History and urinalysis

    Confirm true haematuria, exclude UTI, ask about clots, pain, smoking, occupational exposure and anticoagulation.

  2. 02

    Assessing

    Bloods and renal function

    FBC, U&E, eGFR and clotting - and a PSA in men where appropriate.

  3. 03

    Assessing

    Urine protein and ACR

    Proteinuria with haematuria points to a glomerular (kidney) cause and needs nephrology review.

  4. 04

    Confirming

    Flexible cystoscopy

    A thin camera passed via the urethra to inspect the bladder lining under local anaesthetic - the gold standard for bladder cancer exclusion.

  5. 05

    Confirming

    CT urogram or ultrasound

    CT urogram images the kidneys, ureters and bladder in one study; ultrasound is used for younger or lower-risk patients.

  6. 06

    Directing

    Urine cytology when relevant

    Not routine but useful for high-risk exposures or persistent unexplained findings.

  7. 07

    Directing

    Nephrology referral where needed

    For non-visible haematuria with proteinuria, hypertension or falling eGFR - a glomerular cause needs specialist workup.

Typical timeline: two-week wait to a diagnosis within a fortnight of referral.

Symptoms

What haematuria actually looks like.

The pattern - visible or non-visible, painful or painless, with or without clots - already narrows the diagnosis before any scan.

  • Visible red or pink urine

    Frank haematuria - even a single episode in an adult needs urgent urological assessment.

  • Tea or cola-coloured urine

    Suggests a glomerular source or myoglobinuria - warrants urgent bloods and nephrology input.

  • Clots in the urine

    Clot passage points to a lower urinary tract source and can cause acute retention.

  • Flank or loin pain

    Colicky pain with haematuria raises ureteric stone or upper-tract pathology.

  • Storage symptoms

    Urgency, frequency and dysuria alongside haematuria can indicate bladder cancer or infection.

  • Systemic features

    Weight loss, night sweats, fevers or bone pain - broaden the differential to malignancy.

  • Non-visible on dipstick

    Microscopic blood found on routine testing - two out of three positives on separate samples warrants referral.

  • Red flag - painless visible bleed

    Painless visible haematuria in adults over 45 is bladder cancer until proven otherwise.

Treatment

How haematuria is managed in the UK.

The bleeding itself is rarely the target - management follows the underlying diagnosis, from infection to stones to bladder cancer.

  • Treat the underlying cause

    Haematuria is a symptom, not a diagnosis - management depends entirely on what the investigations reveal.

  • Antibiotics for UTI

    Confirmed urinary infection with haematuria is treated with a course guided by culture, then re-tested to confirm resolution.

  • Stone management

    Ureteric or renal stones may need conservative care, ureteroscopy, shockwave lithotripsy or PCNL depending on size and site.

  • Bladder tumour resection

    TURBT (transurethral resection of bladder tumour) is the mainstay for non-muscle-invasive disease, with intravesical BCG or mitomycin as needed.

  • Prostate treatments

    Enlarged prostate causing bleeding may benefit from medical therapy, HoLEP laser prostatectomy or UroLift where anatomy allows.

  • Nephrology-led care

    Glomerular disease is managed by kidney specialists - biopsy, immunosuppression and blood pressure control where indicated.

  • Anticoagulation review

    Anticoagulants can unmask urological disease - continue investigating rather than assuming the drug is the cause.

  • Surveillance cystoscopy

    After bladder cancer treatment, regular flexible cystoscopy is central to long-term follow-up.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP or urologist knows your history and can tell you which parts apply to you. If you have seen blood in your urine, get seen.

  • NICE. Suspected cancer: recognition and referral (NG12).

  • British Association of Urological Surgeons (BAUS). Haematuria guidelines.

  • NICE. Bladder cancer: diagnosis and management (NG2).

  • Renal Association and BAUS joint consensus on haematuria referral.

Red flags

When haematuria needs urgent attention.

Most cases are worked up in outpatient clinic. These are the presentations that jump the queue - and why.

  • Painless visible haematuria over 45

    A NICE NG12 two-week wait referral - bladder cancer must be excluded promptly with cystoscopy and imaging.

  • Clot retention

    Inability to pass urine because of clot burden - an emergency needing catheterisation and bladder irrigation.

  • Haemodynamic compromise

    Heavy visible bleeding with tachycardia or hypotension needs A&E assessment and urgent urology input.

  • Falling eGFR with haematuria

    Any rapid decline in kidney function alongside blood suggests glomerular disease and warrants urgent nephrology review.

  • Proteinuria plus haematuria

    A red flag for glomerulonephritis, IgA nephropathy or vasculitis - nephrology referral, not urology alone.

  • Suspected upper-tract tumour

    CT urogram findings of a filling defect or mass warrant urgent urology multidisciplinary review.

  • Recurrent unexplained haematuria

    Even after a normal first workup, repeat presentation deserves fresh investigation - do not assume benign.

  • Occupational or smoking exposure

    Rubber, dye, leather industry or heavy smoking increases bladder cancer risk - lower the threshold for referral.

  • Family history of urological cancer

    A strong first-degree family history should shift risk assessment upwards and prompt earlier imaging.

Living with it

A symptom, not a sentence.

Four things that make the biggest difference - completing the pathway, hydrating well, stopping smoking, and reporting recurrence early.

A quiet reminder

A clear scan today does not close the case tomorrow.

Any new visible haematuria after a normal workup still deserves fresh review - one clear investigation is a snapshot, not a lifetime clearance.

  1. 01 Follow-up

    Complete the pathway

    Even if the first test is normal, complete the recommended cystoscopy and imaging - single tests can miss disease.

  2. 02 Hydration

    Drink well, monitor colour

    Adequate fluids help flush the tract and make it easier to spot recurrence early.

  3. 03 Lifestyle

    Stop smoking

    Smoking is the single biggest modifiable risk factor for bladder cancer - stopping halves risk over ten years.

  4. 04 Escalate

    Report new bleeding promptly

    After a clear workup, any new visible haematuria still needs re-referral - do not wait and see.

Frequently asked

Everything we get asked about blood in urine.

Quick answers on the 2WW pathway, cystoscopy, kidney causes and anticoagulation.

  • What is haematuria?

    Haematuria is the presence of blood in the urine. It can be visible (frank or macroscopic) with pink, red or tea-coloured urine, or non-visible (microscopic) - detected only on dipstick or microscopy. Both forms need a clinical explanation, though visible haematuria carries the highest risk of underlying urological cancer and always warrants specialist referral.

  • Do I need a two-week wait referral?

    NICE NG12 recommends urgent (two-week wait) referral for adults aged 45 and over with unexplained visible haematuria - either without a UTI, or persisting after successful treatment of a UTI. It also applies to adults 60 and over with unexplained non-visible haematuria plus either dysuria or a raised white cell count on a blood test. Your GP will assess against these criteria.

  • What tests will I have?

    The two workhorse tests are flexible cystoscopy (a thin camera passed via the urethra to inspect the bladder under local anaesthetic) and CT urogram (a specialised CT scan of the kidneys, ureters and bladder). You will also have urine tests, blood tests including kidney function, and often a PSA in men. Ultrasound is sometimes used in younger or lower-risk patients.

  • Could it just be a urinary infection?

    UTIs can cause visible or non-visible haematuria, but the blood should resolve completely after successful treatment. If it does not, or if the picture is atypical (an older man, no burning, no positive culture), infection is not enough of an explanation and further investigation is needed. See our full guide at /conditions/haematuria/ for the detailed clinical framework.

  • What if my kidneys are the source?

    Blood coming from the glomeruli of the kidney - typically producing tea-coloured urine, proteinuria and sometimes hypertension or falling kidney function - is a nephrology problem, not a urology one. Conditions like IgA nephropathy, thin basement membrane disease or vasculitis are managed by kidney specialists, sometimes with a kidney biopsy.

  • Is it dangerous to be on blood thinners with haematuria?

    Anticoagulants and antiplatelets can unmask underlying urological disease rather than cause bleeding on their own. Current UK consensus is to investigate haematuria on the same pathway regardless of anticoagulation - stopping the drug or blaming it prematurely can delay a serious diagnosis. Any change to anticoagulation should be discussed with the prescribing team.

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