• Consider referring for assessment and investigation if the man fails to respond to two courses of antibiotic shown by urine culture to be appropriate treatment, and treatment adherence has been verified.
• If cancer is suspected, refer urgently. Refer the man to a team specializing in the management of urological cancer if:
• He is of any age, with macroscopic haematuria and urine culture fails to confirm a urinary tract infection (UTI) or the haematuria does not resolve with treatment of a UTI. 
• He is 40 years of age or older, and presents with recurrent or persistent UTI associated with haematuria.
• He is 50 years of age or older, and has unexplained microscopic haematuria — exclude causes such as the urinary catheter and infection.
• An abdominal mass is identified (clinically or on imaging) that is thought to arise from the urinary tract.
• If there is persistent microscopic haematuria, and this is not thought to be caused by a urinary catheter:
• Refer for urological assessment those men younger than 50 years of age who do not have proteinuria or raised serum creatinine.
• Refer for renal assessment those men with proteinuria or raised serum creatinine.

Referral for failure to respond to appropriate antibiotics

• The recommendation to consider referring men who have failed to respond to an appropriate antibiotic (shown by urine culture) is pragmatic, as CKS found no direct evidence from clinical trials or recommendations in national guidelines.

Urgent referral for urological cancer

• The recommendation to refer men with suspected urological cancer is based on criteria in guidelines from the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Primary Care, 2005].