An unusual presentation of bladder cancer

 

Mr C is a 65 year-old retired accountant who was referred to Melbourne Urology Centre for further investigation and management of bothersome lower urinary tract symptoms (LUTS).

 

HISTORY

Mr C’s symptoms were predominantly storage urinary symptoms of daytime urinary frequency (urinating too often) and occasional urinary urgency (strong desire to urinate). His most bothersome symptom was nocturia (waking at night to pass urine) 3-4 times. The symptoms were of fairly recent onset (months) and with no obvious precipitant. His fluid intake was unremarkable, rarely drinking alcohol, tea, coffee or other caffeinated drinks. He is also a heavy smoker. There was no history of urinary tract infection or visible haematuria (blood in the urine) nor family history of prostate disease. He takes low-dose aspirin as primary prevention.

 

EXAMINATION

Physical examination was unremarkable; the prostate was moderately enlarged but benign-feeling (non-cancerous).

 

INVESTIGATIONS

Prior to his appointment, Mr C’s family doctor arranged a urine microscopy and culture which showed small volume microscopic haematuria (non-visible blood in urine) but no sign of infection. Renal tract ultrasound demonstrated bladder wall thickening with some mild irregularity and an enlarged 50cc prostate.

Urinary flow rate was performed in the rooms with a maximum flow of 14ml/sec (normal >15mls/sec) and small residual volume of 30ml, the kidneys were normal.

Urine cytology x 3 was negative for malignancy.

A flexible cystoscopy was performed to directly visualize the bladder. This revealed a 2cm bladder tumour. The diagnosis was explained to Mr C and he was promptly scheduled for rigid cystoscopy and transurethral resection of bladder tumour (TURBT).

 

TREATMENT

TURBT was uneventful and Mr C was discharged home after an overnight hospital stay. The histopathology revealed a low-grade, non-invasive urothelial tumour. He was placed on a cystoscopic bladder cancer surveillance program with the first check to be performed after 3 months.

 

DISCUSSION POINTS – BLADDER CANCER

  • Bladder cancer can present as recent onset of urinary symptoms. The majority of tumours are low grade and superficial (non-invasive). High-grade or invasive tumours require aggressive treatment to prevent the cancer from spreading
  • The most common presentation is painless haematuria (visible blood in urine), however it may be asymptomatic (microscopic haematuria) or present with storage urinary symptoms (frequency, urgency, nocturia as described in this case)
  • Tobacco smoking is the biggest risk factor
  • All patients with lower urinary tract symptoms should have a urine dipstick test. Formal urine microscopy, culture and cytology should be done if there is any abnormality
  • Not all male Lower Urinary Tract Symptoms (LUTS) are caused by benign prostatic hyperplasia (BPH/prostate enlargement)
  • Haematuria/blood in urine (including microscopic) is never normal and always requires investigation
  • Prompt referral to a Urologist ensures rapid investigation, diagnosis and treatment of bladder cancer; delay in diagnosis leads to poor outcomes
  • Imaging (ultrasound or CTIVP) is useful for upper-tract (kidney or ureteric) tumours but has poor utility in detecting bladder cancer
  • Direct cystoscopic evaluation of the bladder is essential
  • Urine cytology has poor utility in low grade urothelial however is positive in up to 75% of patients with high grade tumours or carcinoma in-situ (CIS) and may be performed in cases with a high index of suspicion