urgent referral for suspected bladder cancer

Last edited 01/2022 and last reviewed 12/2022

Prostate cancer

• refer men using a suspected cancer pathway referral (for an appointment within 2 weeks) for prostate cancer if their prostate feels malignant on digital rectal examination
  
  
• consider a prostate-specific antigen (PSA) test and digital rectal examination to assess for prostate cancer in men with:
  • any lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy, urgency or
  • retention or
  • erectile dysfunction or
  • visible haematuria
    
    
• refer men using a suspected cancer pathway referral (for an appointment within 2 weeks) for prostate cancer if their PSA levels are above the age-specific reference range

Bladder cancer

• refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for bladder cancer if they are:
  • aged 45 and over and have:
    • unexplained visible haematuria without urinary tract infection or
    • visible haematuria that persists or recurs after successful treatment of urinary tract infection, or
    • aged 60 and over and have unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test
      
      
  • consider non-urgent referral for bladder cancer in people aged 60 and over with recurrent or persistent unexplained urinary tract infection

Renal cancer

• refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for renal cancer if they are aged 45 and over and have:
  • unexplained visible haematuria without urinary tract infection or
  • visible haematuria that persists or recurs after successful treatment of urinary tract infection

Testicular cancer

• consider a suspected cancer pathway referral (for an appointment within 2 weeks) for testicular cancer in men if they have a non-painful enlargement or change in shape or texture of the testis
• consider a direct access ultrasound scan for testicular cancer in men with unexplained or persistent testicular symptoms

Penile cancer

• consider a suspected cancer pathway referral (for an appointment within 2 weeks) for penile cancer in men if they have either:
  • a penile mass or ulcerated lesion, where a sexually transmitted infection has been excluded as a cause, or
  • a persistent penile lesion after treatment for a sexually transmitted infection has been completed
    
    
• consider a suspected cancer pathway referral (for an appointment within 2 weeks) for penile cancer in men with unexplained or persistent symptoms affecting the foreskin or glans
  • include progressive ulceration or a mass in the glans or prepuce particularly, but can involve the skin of the penile shaft. (Lumps within the corpora cavernosa can indicate Peyronie’s disease, which does not require urgent referral.) (2)

Notes:

• PSA testing of asymptomatic men or screening for prostate cancer is not a national screening policy. It is recommended that a PSA test, except in men clinically suspicious of prostate cancer should only be performed after provision of written information and full counselling.
• NICE state (1):
• consider a prostate-specific antigen (PSA) test and digital rectal examination to assess for prostate cancer in people with:
  • any lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy, urgency or retention or
  • erectile dysfunction or
  • visible haematuria
    
    
• consider referring people with possible symptoms of prostate cancer, using a suspected cancer pathway referral (for an appointment within 2 weeks) for prostate cancer if their PSA levels are above the threshold for their age in table below. Take into account the person's preferences and any comorbidities when making the decision.

Age-specific PSA thresholds for people with possible symptoms of prostate cancer

Age (years)	Prostate-specific antigen threshold (micrograms/litre)
Below 40	Use clinical judgement
40 to 49	More than 2.5
50 to 59	More than 3.5
60 to 69	More than 4.5
70 to 79	More than 6.5
Above 79	Use clinical judgement

• (Note that there are no age-specific reference ranges for men over 80 years. Nearly all men of this age have at least a focus of cancer in the prostate. Prostate cancer only needs to be diagnosed in this age group if it is likely to need palliative treatment.) (2)
• exclude urinary infection before PSA testing. Postpone the PSA test for at least 1 month after treatment of a proven urinary infection (2)

Reference:

• NICE (December 2021). Referral Guidelines for Suspected Cancer
• NICE (June 2005). Suspected cancer: recognition and referral