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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
        • expedites treatment for non-muscle-invasive bladder cancer
  • 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
        • normal shaped RBCs suggest an extra-renal bleeding source, like the bladder
  • 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
        • initial treatment of non-muscle invasive bladder tumor
        • provides histological confirmation of bladder cancer
Complications
  • Urinary obstruction
  • Surgical complications
    • urinary incontinence
    • sexual dysfunction
    • impaired bowel function
 

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Questions (2)

(M2.ON.14.78) A 65-year-old previously healthy man presents to the primary care physician with the chief complaint of red colored urine over the past month. He states that he does not experience dysuria. On physical exam there is no costovertebral angle tenderness. With this presentation which is the most likely cause of this patient's hematuria? Tested Concept

QID: 104525
1

Bladder tumor

75%

(12/16)

2

Renal cell carcinoma

19%

(3/16)

3

Beeturia

0%

(0/16)

4

Urinary tract infection

0%

(0/16)

5

Urethral injury

0%

(0/16)

M 6 E

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