A Mail Carrier With Gross Hematuria Whose Sister Has Lupus

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


October 12, 2021

Although painless hematuria should prompt suspicion of a possible underlying bladder carcinoma, other pertinent aspects of a patient's medical history may influence a provisional diagnosis and subsequently delay necessary workup. For example, in this case, the patient is receiving long-term anticoagulation, which is known to have the possible adverse effect of hematuria.[1] This situation can result in delayed referral to a urologist for further workup.

Anticoagulation-associated hematuria and the likelihood of underlying bladder cancer have been the subject of debate. Some studies have shown that the cause of hematuria in patients who are receiving anticoagulation is more commonly nonurologic.[1,7] However, Wallis and colleagues[8] found that patients with anticoagulation-associated hematuria were more likely to receive a diagnosis of bladder cancer than were both patients who were not taking antithrombotic medication and the general population. The risk for cancer as the underlying cause of anticoagulation-associated hematuria is not negligible. Thus, investigators recommend prompt urologic evaluation to prevent a potential detrimental delay in bladder cancer diagnosis.[1,9]Despite patients being on anticoagulation, the presence of gross hematuria should be evaluated with upper tract imaging and cystoscopy, especially among those with risk factors.

Timely diagnosis is important because bladder cancer can be associated with significant morbidity and mortality.[6] The clinical stage of the primary bladder tumor is one of the most important factors in determining prognosis and survival. Features that contribute to the clinical stage, such as depth of tumor invasion, are time sensitive, and delays in diagnosis are associated with worse outcomes. One study found that patients who were referred to a specialist within 14 days of symptom onset had higher survival rates than those whose evaluation was delayed past 2 weeks.[10] Therefore, early detection and diagnosis with timely intervention in patients with risk factors and clinical signs suggestive of possible bladder cancer are crucial in optimizing long-term outcomes.

Currently, routine screening for bladder cancer is not recommended in asymptomatic adults.[11] However, symptoms of bladder cancer, particularly hematuria, are an indication for a thorough evaluation of the urinary tract in most cases. Various diagnostic studies can be used in the evaluation of bladder cancer. Urine cytology can be useful in this setting by identifying malignant cells.[12] Reasonable imaging modalities include ultrasonography, intravenous urography, CT, and MRI. The ultrasound scan (Figure 2) and the CT scan (Figure 3) shown here reveal masses in the bladders of different patients.

Figure 2.

Figure 3.

Ultrasonography is typically readily available, cost-effective, and noninvasive. Its role has been evaluated in several studies, with conflicting evidence regarding its ability to identify bladder tumors.[13] In addition, the quality of imaging is operator dependent and may be limited by other factors, such as patient body habitus. Therefore, although any of these imaging studies may be obtained, cystoscopy remains the gold standard for the initial evaluation of bladder cancer.[3] It is the ideal diagnostic study because it allows for direct visualization of the bladder and any lesions or tumors that may have otherwise been difficult to detect or that were missed on imaging. The cystoscopy image shown below reveals urothelial cell carcinoma of the bladder in a different patient (Figure 4).

Figure 1.

Cystoscopy also provides information on tumor features, including location, size, and characteristics that allow classification of the tumor. Biopsy or resection of the tumor should be performed during cystoscopy to permit definitive diagnosis and histologic assessment of the depth of tumor invasion into the bladder wall muscle, which helps guide management.[5]


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