How should I approach the investigation of a patient with hematuria to

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Approach to investigating a patient with hematuria to exclude bladder cancer:

Refer patients aged 45 years and over with unexplained visible hematuria without urinary tract infection (UTI) urgently via a suspected cancer pathway for specialist assessment within 2 weeks ,,.
Refer patients aged 45 years and over with visible hematuria that persists or recurs after successful treatment of UTI urgently via a suspected cancer pathway ,,,.
Refer patients aged 60 years and over with unexplained non-visible hematuria accompanied by dysuria or a raised white cell count on blood tests urgently via a suspected cancer pathway ,,,.
Initial investigations in primary care should include urine dipstick and microscopy to confirm hematuria and exclude infection, and urine culture if UTI is suspected .
If UTI is present, treat appropriately and reassess; persistent or recurrent hematuria after treatment warrants urgent referral ,.
Do not rely on urinary biomarkers alone to exclude bladder cancer; cystoscopy remains the gold standard investigation for suspected bladder cancer .
Specialist assessment typically includes cystoscopy and imaging such as CT urography to evaluate the bladder and upper urinary tract .
Consider additional investigations such as blood tests and imaging based on clinical features and risk factors ,.

How should I approach the investigation of a patient with hematuria to rule out bladder cancer?