Review Question - QID 214685

This patient has new onset painless hematuria and evidence of a bladder mass on abdominal CT scan suggestive of bladder cancer. The next step in management is a cystoscopy for tissue sampling and diagnosis.

Bladder cancer is the most common type of urothelial cancer, which involves the epithelial lining of the urinary tract. Risk factors for bladder cancer include male sex, history of smoking or exposure to carcinogens, chronic infections, and cyclophosphamide. Patients typically present with painless hematuria throughout micturition with irritative voiding symptoms. The majority of cancers are transitional cell carcinomas. Urinalysis demonstrates red blood cells without casts (rules out glomerular cause of hematuria) and CT urography and cystoscopy are indicated the initial diagnosis and staging. Treatment of urothelial cancers involves surgical resection with neoadjuvant chemotherapy and/or radiation.

Figure/Illustration A is an abdominal CT demonstrating a mass (red arrow) extending from the bladder wall (yellow arrow) into the lumen (blue arrow).

Incorrect Answers:
Answer 1: Abdominal MRI is used to stage bladder cancers after cystoscopy and cytology have confirmed the diagnosis. This patient requires diagnosis of the bladder mass first.

Answer 3: Renal biopsy is used to evaluate the cause of suspected glomerulonephritis. Although glomerulonephritis may present with painless hematuria, urinalysis would demonstrate red blood cell casts and proteinuria along with red blood cells.

Answer 4: Retrograde urethrogram is used to evaluate urethral tumors. The mass identified on CT in this patient is localized to the bladder wall.

Asnwer 5: Surgery is indicated as definitive treatment for bladder cancer. The mass identified on CT in this patient must be sampled and diagnosed prior to surgery.

Bullet Summary:
Patients that present with painless hematuria with evidence of a bladder mass must undergo cystoscopy in order to diagnose and stage the lesion.