A Mail Carrier With Gross Hematuria Whose Sister Has Lupus

Paige A. Hargis, BS; Katie S. Murray, DO, MS


October 12, 2021


The differential diagnosis for hematuria is wide and involves mostly pathologies associated with the urinary tract. Conditions in the differential include the following:

All of the choices presented are possible etiologies for hematuria. Benign prostatic hyperplasia is usually accompanied by lower urinary tract symptoms, such as frequency, urgency, weak stream, and incomplete emptying, which were not present in this patient. Therefore, this diagnosis is less likely. Urolithiasis is often associated with dysuria, nausea or vomiting, and back or abdominal pain that may radiate toward the groin. The absence of these symptoms and a normal renal ultrasound reduces the likelihood of this diagnosis.

Cystitis can also cause pain and burning with urination, and urine testing typically shows an elevated WBC count, bacteriuria, nitrites, and a positive leukocyte esterase test. Although this patient had an elevated urine WBC count, he did not have the other characteristic urinalysis findings.

Anticoagulation-associated hematuria is a reasonable differential diagnosis for this patient's hematuria. However, it is more likely to be a consideration when the INR is > 4, and this patient's INR was 3.2.[1]

Gross hematuria in a man in his 60s with a history of cigarette smoking warrants strong suspicion for bladder cancer until proven otherwise. In addition, the cystoscopy images show a lesion on the bladder wall that supports the diagnosis of cancer. Therefore, urothelial cell carcinoma is the most likely diagnosis at this time.

In 2020, an estimated 81,400 new cases of urinary bladder cancer occurred, with an estimated 17,980 deaths.[2] Bladder cancer is the seventh most common cancer throughout the world, and it is the fourth most common cancer in men in the United States. Men are affected about three times more often than women.[3,4]

Urothelial carcinoma is by far the most common type of bladder cancer, occurring in about 90% of cases. Other types of bladder cancer include squamous cell carcinoma and adenocarcinoma. Tobacco use is the leading risk factor for the development of bladder cancer; approximately half of patients with a diagnosis of bladder cancer report a history of smoking. Other notable risk factors include exposure to dyes and rubbers, such as 4-aminobiphenyl, o-toluidine, and benzidine; chemotherapeutic agents (cyclophosphamide); and pelvic radiation therapy.[5]

About 80% of patients with bladder cancer report hematuria, which is the most common presenting symptom.[5] Other lower urinary tract symptoms may include dysuria, urgency, and frequency, or flank pain secondary to obstruction of the urinary tract. A pelvic mass is an atypical finding in a patient who presents with bladder cancer. In addition to generalized symptoms, such as fatigue, weight loss, and abdominal or bone pain, a mass is usually associated with metastasis.[6]


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