Cases/Renal and Urology

Woman Whose Urine Still Shows Blood After Her Infection Was Treated — Free SCA Practice Case

Woman whose urine still shows blood after her infection was treated

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Veronica Harcourt

Age

61 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. Routine appointment booked by the patient.

Reason for Encounter

"I've seen blood in my urine again. I thought the infection was all cleared up."

Medical Records

●PMH: Hypertension. Low mood 12 years ago, resolved.
●Medications: Ramipril 5mg OD.
●Allergies: NKDA.
●Social: Part time school lunchtime supervisor.

Recent Notes

●5 weeks ago: Dysuria, frequency and pink urine for 2 days. Dipstick: blood 2+, leucocytes 2+, nitrite positive. MSU: E. coli, sensitive to nitrofurantoin. Treated with nitrofurantoin 100mg MR BD for 3 days. Symptoms settled.
●Hypertension review 4 months ago: BP 136/80, eGFR 72.

Patient Script

For the friend playing the patient role

Character Overview: You are Veronica Harcourt, a 61 year old part time lunchtime supervisor at a primary school. You work three days a week and the children are the best part of it. You live with your husband Ivor, who retired from the council a few years ago, and your daughter Saskia lives about an hour away with her partner. You are practical, a bit self deprecating and used to getting on with things without making a fuss. You had a water infection about five weeks ago, the tablets cleared it, and you felt fine. Four days ago you saw pink and then red urine again. It has happened twice since, and it does not hurt. You rang for an appointment because Ivor told you to, and you expect to be given another course of antibiotics. You speak briskly and cheerfully at first, and your voice becomes quieter and less steady when the worry comes out. You never use medical terms for the problem. You describe it as blood in your wee.

Opening Sentence: "Hello, doctor. Sorry to bother you, it's probably nothing, but I've seen blood in my wee again this week. I had that water infection last month and I thought it was all sorted."

History if Asked (Data Gathering Phase)

●The first episode: "About five weeks ago. It stung, I was running to the toilet every half hour and the wee was pink. I gave a sample, they said it was an infection and I had three days of tablets. By the end of the third day it all felt fine."
●Between the episodes: "It was clear again after the tablets. About three weeks of normal wee, then it came back this week."
●This episode: "Four days ago. The first one was pink, then one that was properly red, and I've seen it twice since. In between it looks normal. Today's first wee of the morning was a bit pink again."
●Where in the stream: "It seems to be all the way through. I haven't noticed it just at the start or at the end."
●Clots: "A couple of tiny stringy bits yesterday. Nothing big, and I've been able to pass water fine."
●Pain and infection symptoms: "No, that's what's odd. Last time it stung like mad. This time it doesn't hurt at all. I'm not going more often and there is no burning."
●Back or tummy pain: "No pain in my sides or my back. No tummy ache."
●Fever: "No, I haven't felt hot or shivery."
●Weight and appetite: "My weight is the same as far as I know. I'm eating normally. I'm a bit tired but I've been on my feet all week."
●Vaginal bleeding: "No. My periods stopped about ten years ago and I've had nothing since. The blood is definitely coming out when I wee."
●Trauma or exercise: "No falls. I haven't done anything strenuous."
●Stones or kidney problems: "Never. No kidney trouble and no stones."
●Other symptoms: "No problems getting the wee out and no leaking. I get up once in the night, which is normal for me."

Ideas, Concerns, Expectations

Gating note: Veronica does not volunteer any of the following. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for.

●Ideas: She thinks the infection was not completely cleared by the three days of tablets and has flared up again. A friend had a water infection that "kept coming back" until she took a longer course. "I think it's still lurking. Three days wasn't long enough, was it?"
●Concerns: She hides her real worry until she feels listened to. Then she admits she keeps thinking about something worse. Her mother died of cancer in her sixties and she smoked for years herself. She says she has been lying awake at night. She does not say the name of a particular cancer. "I haven't told Ivor how much it's bothering me. I keep thinking, what if it's something worse, with the smoking and everything."
●Expectations: She expects a stronger or longer course of antibiotics, perhaps after a sample. She would like someone to tell her it is nothing. If the doctor suggests a hospital referral, she is frightened but accepts it. "I was hoping for a different tablet, something that finishes it off properly."

If Asked: Medical History and Medications

Gating note: Veronica answers each of these plainly when the doctor asks about it.

●Other health problems: "Blood pressure, which is fine on the tablets. I had a low patch about twelve years ago after my mother died, and I got through it. Nothing else."
●Medicines: "Ramipril, one a day. I take paracetamol for a headache now and then and nothing else. No blood thinners, no aspirin and no herbal tablets."
●Allergies: "None."
●Infections: "That one last month is the only water infection I've had in years."
●Bleeding problems: "I don't bruise easily and I've never had a bleeding problem. I had a nosebleed once as a child."
●Family history: "Mum died of cancer of the pancreas in her sixties. Nobody has had kidney or bladder problems, as far as I know."
●Cervical screening and tests: "All up to date, I think."

Social History and Lifestyle Impact

●Smoking: If asked, she says she smoked about 20 a day for 30 years and gave up eight years ago, after a chest infection that frightened her. She has not smoked since. She is a little embarrassed. "I know, I know. Thirty years of it."
●Past work: If asked about earlier jobs or chemicals, she says that in her twenties she worked for about ten years in a textile dyeing factory, mixing dyes by hand. She had not thought it mattered until now.
●Alcohol: "A glass of wine at the weekend."
●Work: Three days a week at the school, on her feet through the lunch hour. She says she can ring in if she needs to see someone.
●Home: Lives with Ivor, who worries and fusses. She has not told Saskia, who is busy with her new job, and does not want to alarm her.
●Availability and contact: Available any day and can answer a mobile phone at any time, including during the school day.

If Asked: Associated Symptoms

Gating note: Veronica answers these only when asked. Every one is negative unless stated.

●If asked about weight loss, night sweats, or loss of appetite: "No, none of that."
●If asked about bone pain, cough or coughing up blood: "No. My chest has been fine since I gave up smoking."
●If asked about swelling in the legs, or passing very little urine: "No."
●If asked about a lump in the tummy or back pain: "Not that I've noticed."
●If asked about bowel changes or blood from the bottom: "No, my bowels are normal."
●If asked about a recent sample, dipstick or blood test today: "I haven't given one this week. I wasn't sure if I should."
●If asked about medicines like warfarin or tablets that thin the blood: "No, nothing like that."

Responses to Management (The Negotiation Phase)

●
If the doctor says she needs to be seen urgently by a specialist, or that this could be serious:
- ●Reaction: Taken aback, then tearful. "Oh. Is it cancer? Is that what you think?" If told honestly that blood that comes back after an infection needs to be checked quickly to rule out something serious such as a growth in the bladder or kidney, and that many people referred do not have cancer: "Right. Right. I did wonder." If the doctor falsely says it is nothing to worry about: "So why the hurry, then?"
●
If the doctor wants to treat with more antibiotics instead, or send a sample first and wait:
- ●Reaction: Hopeful, pleased, then she asks the question. "Great, a stronger tablet. And if the blood is still there after that, then what?" She is happy to give a sample today.
●
If the doctor explains what will happen at the hospital:
- ●Reaction: Anxious and practical. "What will they do, and will it hurt? How soon is it? Do I just get a letter?" If told she will be seen quickly, that she will be contacted by phone and should answer unknown numbers: "I always answer, because of school. What if nobody rings?" She is calmer when given a plan for that.
●
If the doctor mentions tests or a scan to arrange alongside the referral:
- ●Reaction: Willing. "I can pop in for a blood test any day, I only work three days." If told the referral will not be held up by these tests: "Good. I don't want it delayed."
●
If the doctor asks about her fears, or her smoking and her mother:
- ●Reaction: Opens up. "Mum went so quickly. I don't want Ivor to go through that again." She says she is glad to have been asked. If the doctor blames her smoking: "I know. I've been telling myself that all week."
●
If the doctor gives safety netting:
- ●Reaction: Wants specifics. "What counts as an emergency? What if I can't pass water because of a clot?" If the safety netting is vague, such as "come back if it gets worse": "Worse how? It's already coming and going." She repeats back clearly when given specific symptoms and what to do.

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Veronica is 61 and has had visible blood in her urine on and off for four days, with no pain. Five weeks ago a culture confirmed an E. coli urine infection that settled after a short course of nitrofurantoin, and her urine was clear for about three weeks afterwards. She expects a stronger antibiotic. The station tests whether the candidate resists treating a familiar infection pattern and recognises that visible haematuria (blood the patient can see) that recurs after a successfully treated infection needs a suspected cancer assessment.
●The model plan has five parts. Take a focused history that confirms the blood is visible, painless and from the urinary tract, and that explores smoking, past occupation and her fears. Make a suspected cancer pathway referral to urology promptly, during or straight after the call, with the earlier infection and her risk factors in the referral. Do not prescribe more antibiotics. Arrange a urine sample and blood tests alongside, without holding the referral for the results. Finish with specific safety netting, a clear explanation of what happens next, and a follow up call to check the referral has been received.
●Acceptable alternatives: asking her to come in for a blood pressure check, an examination or a urine dipstick on the same day or the next, provided the referral is not held until that visit. A urine culture is also reasonable, provided the referral does not depend on its result. A short telephone follow up in a few days to confirm the appointment is both acceptable and good practice.

Why This Is Not a Relapse of Infection

●NICE guideline NG12 (Suspected cancer: recognition and referral, 2026 revision) recommends a suspected cancer pathway referral for bladder cancer in people aged 45 and over with unexplained visible haematuria without a urinary tract infection, or with visible haematuria that persists or recurs after successful treatment of a urinary tract infection. The same two criteria apply to suspected renal cancer.
●Veronica meets the second criterion exactly. The first infection was confirmed on culture, treated with a short course and followed by a symptom free, clear interval. The second episode is painless, with no dysuria, frequency or fever, which makes a second infection unlikely.
●NG12 also advises referral for people aged 60 and over with unexplained non visible haematuria (blood found only on testing) and either dysuria or a raised white cell count. It suggests considering a non urgent referral for people aged 60 and over with recurrent or persistent unexplained urinary tract infection.

Causes, Risk Factors and Why History Matters

●Haematuria in a woman of this age may come from the bladder, ureters or kidneys. Causes include bladder or kidney cancer, stones, infection and glomerular (kidney filter) disease. Bladder cancer is the commonest cause of painless visible haematuria in this age group.
●Smoking is the strongest risk factor for bladder cancer. Occupational exposure to aromatic amines, which were used in dye, rubber and chemical industries, can also raise risk, often decades after the exposure. Textile dyeing with older dyes is one such exposure. Her ten years in a dye factory are therefore important. Many candidates will ask only about current smoking. Stopping smoking lowers risk but does not remove it, so her having stopped eight years ago is no reason to relax.
●Vaginal and bowel bleeding can be mistaken for blood in the urine, and a woman of this age may have post menopausal bleeding, which would need a gynaecology referral. Veronica has had no bleeding since the menopause and she is sure the blood is coming from the urinary tract.
●Do not attribute visible haematuria to a blood thinner, aspirin or a recent minor injury without investigation. Veronica takes none, but the habit of looking for an easy explanation is the trap in this station.

Assessing Remotely

●Everything the case hinges on can be gathered by phone: timing, painlessness, clots, ability to pass urine, risk factors and associated symptoms. The abdominal examination and blood pressure check do not change the decision to refer, so a candidate who says that she must come in first is delaying a pathway the history already justifies.
●Ask about loin pain, fever and weight loss, which could suggest kidney involvement, an obstructed kidney or advanced disease. All are absent here, which supports an urgent referral rather than an emergency one.

Tests Alongside the Referral

●A urine sample for culture and bloods such as full blood count and kidney function (urea and electrolytes, estimated glomerular filtration rate) are reasonable to arrange at the same time. They help show whether there is a current infection and whether kidney function or haemoglobin is affected. They do not replace the referral and a normal result would not change the plan. These tests are common practice rather than an NG12 requirement, and local haematuria pathways may specify their own, so they are not marked as essential.
●Do not wait for results before sending the referral. NG12 says to refer when the criteria are met. A clear urine culture could falsely reassure both the doctor and the patient.
●Do not prescribe empirical antibiotics. There is no sign of infection, and a course could make the blood settle for a while, which delays the diagnosis.

What the Specialist Will Do

●A suspected cancer pathway referral for haematuria usually leads to a rapid access haematuria clinic. The usual assessment is a flexible cystoscopy, a short camera test of the bladder under local anaesthetic gel, and imaging of the upper urinary tract, often with ultrasound or a CT scan. Many areas offer both on one visit. Local pathways and imaging vary, so a candidate should not promise a specific test or a single visit.
●NG12 defines a suspected cancer pathway referral as one after which the person should receive a diagnosis or have cancer ruled out within 28 days (the NHS England Faster Diagnosis Standard). The first specialist appointment is expected to be much sooner, but the exact wait varies locally, so a candidate should say she will be seen quickly rather than promise a date.
●It is important to say that urgent does not mean a cancer is certain. Most people referred with haematuria do not turn out to have cancer, but the check cannot be skipped because early diagnosis changes outcomes.

Communicating with a Frightened Patient

●Veronica says that the problem is "probably nothing" and expects antibiotics. The first task is to find out what she thinks, then to address it. She believes the infection was not fully cleared, and a clear and kind explanation that the bleeding has a different pattern from last time is more persuasive than a flat refusal.
●Her worry is cancer, shaped by her mother's death and her smoking. If the candidate does not ask, she will leave with the fear unspoken and be left to lie awake. Naming the possibility in plain words is kinder than avoiding it.
●Honesty matters more than reassurance. Saying "it is probably nothing" before an urgent referral is contradictory and will break trust. Saying "you have cancer" is equally wrong, because no diagnosis has been made.
●Smoking should be mentioned only as a risk factor she has already acknowledged, never as blame. She stopped eight years ago, which is worth recognising.

Safety Netting and Follow Up

●She should seek help the same day, by phoning the surgery or NHS 111, if she has fever or shivering, severe loin pain, or heavy bleeding. She should call 999 or go to the emergency department if she cannot pass urine, passes large clots, or feels faint or very unwell.
●Tell her to answer unknown numbers over the next few weeks, since the hospital may ring from a withheld number, and to contact the surgery if she has had no contact within the timeframe given.
●Record her mobile number on the referral. The surgery should check that the referral has been received and that an appointment has been made.

Common Mistakes in This Station

●Prescribing another course of antibiotics because she asks, or telling her to send a sample and wait for the result.
●Making a routine referral, or planning to refer only if the blood returns a third time.
●Holding the referral until blood tests, a urine culture or a face to face visit has taken place.
●Not asking about smoking in years and past occupation, or about vaginal bleeding.
●Telling her it is probably nothing, or stating that it is cancer.
●Using terms such as haematuria, cystoscopy or suspected cancer pathway without explanation.
●Safety netting with "come back if it gets worse" and no named symptoms, with no plan for what to do if she cannot pass urine.
●Missing her hint that she is worried, or lecturing her about smoking.

Mapped to the RCGP curriculum topic: Renal and Urology.

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