A Mail Carrier With Gross Hematuria Whose Sister Has Lupus

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


October 12, 2021

The complications of bladder cancer are typically related to tumor burden or symptoms associated with treatment.[3] Progressive bladder cancer can cause constitutional symptoms, such as fatigue, anorexia, weight loss, and weakness. Metastatic disease can lead to the development of other symptoms depending on the location of metastasis; for example, bone metastasis can result in localized bone pain. Tumors can progress to cause symptoms of mass effect, such as urinary tract obstruction that causes hydronephrosis and eventual kidney failure. Patients may also develop symptoms related to adverse effects of chemotherapy or radiation treatment. Potential complications of surgery include urinary incontinence, erectile dysfunction, and vaginal narrowing.

A shared decision-making approach to discuss the treatment of bladder cancer with patients is critical.[11] Management is largely determined by the stage of the tumor, particularly whether it has invaded the muscle; other tumor characteristics; and the patient's surgical candidacy.[3] Algorithms can help guide standardized therapy in patients with bladder cancer.[11] In general, the options are surgery; chemotherapy; radiation therapy; immunotherapy; targeted therapy; or, more commonly, a combination of these treatments.[14] Common surgical interventions include transurethral resection of bladder tumor (TURBT), partial cystectomy, or radical cystectomy with urinary diversion. The video shows TURBT being performed in a different patient with bladder cancer.


Systemic or intravesical chemotherapy may be used, including as adjuvant or neoadjuvant therapy. Intravesical immunotherapy with bacillus Calmette-Guérin (BCG) vaccine has been associated with high survival rates in patients at elevated risk.[15] Radiation therapy may be used, usually in conjunction with chemotherapy, owing to high recurrence rates reported in patients treated with radiation alone.[11] Immunotherapy, including checkpoint inhibitors, is typically indicated in patients with refractory cancer.[11] Overall, the treatment of bladder cancer is complex, and many different factors are taken into account when determining the appropriate management strategy for each patient.

In this case, the patient received a diagnosis of T1 high-grade urothelial carcinoma, an aggressive form of bladder cancer. TURBT was performed, with repeated resection at 4 weeks and subsequent intravesical BCG treatment. Surveillance cystoscopy at 6 months showed no tumor recurrence.

This case is an example of a patient who received a delayed cancer diagnosis because of the bias toward a diagnosis of benign hematuria in a patient on anticoagulation therapy. This patient did not present with many notable symptoms, which made benign anticoagulation-associated hematuria an appealing differential diagnosis. However, painless hematuria may be the only presenting symptom in a patient with underlying bladder cancer. Owing to the potential morbidity and mortality that can be associated with bladder cancer, prompt evaluation and a thorough workup of hematuria, including cystoscopy, are necessary to rule out severe disease.


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