Snapshot A 65-year-old man presents to his primary care physician after noticing blood in his urine. He reports that his urinary stream is normal but notices blood at the end of urination. He denies any abdominal pain, dysuria, or urinary frequency or urgency. Medical history is unremarkable. He smokes 1 pack of cigarettes daily for the past 35 years. Physical examination is unremarkable. Urinalysis demonstrates a large red blood cell count with normal red blood cell morphology. He eventually undergoes cystoscopy, which demonstrates a protruding mass from the bladder wall. Introduction Overview malignancy of the bladder the predominant histologic type is transitional cell carcinoma (~90% of cases) bladder cancers can be superficial (non-muscle invasive), muscle invasive, and metastatic in nature Epidemiology Risk factors smoking nitosamines aniline dyes phenacetin cyclophosphamide Schistosoma haematobium typically leads to squamous cell carcinoma of the bladder Presentation Symptoms painless hematuria can be microscopic or grossly visible hematuria occuring towards the end of voiding typically suggests a bladder neck or prostatic urethra source irritative voiding symptoms may be present urinary urgency, frequency, and dysuria the presence of pain suggests invasive and/or metastatic disease Imaging Cystoscopy indication gold standard for the initial diagnosis and staging of bladder cancer assess if the bladder cancer is muscle-invasive or not login to view 1 more bullet CT of the abdomen and pelvis indication performed with and without contrast and is considered the imaging study of choice to evaluate the local extent of disease and to assess the renal pelvis and ureters Studies Urinalysis indication evaluates for the presence of blood in the urine the morphology of the red blood cells (RBCs) suggests its source login to view 1 more bullet Cystoscopy indication abnormal bladder imaging, abnormal urine cytology, obstructive symptoms with possible tumor, stricture, or stone, recurrent UTIs, hematuria with no glomerular disease Urine cytology indication used in combination with cystoscopy to determine if there is carcinoma in situ and the presence of upper urinary tract lesions Differential Prostate cancer differentiating factors elevated prostate-specific antigen nodular and irregular prostate on digital rectal examination Treatment Surgical transurethral resection of bladder tumor (TURBT) indication login to view 2 more bullets