QuestionSBA
QuestionChoice
This patient has haematuria with voiding lower urinary tract symptoms. He should therefore be investigated for malignancy in a dedicated one-stop clinic in the first instance. Transurethral resection of the prostate is performed for benign prostatic hypertrophy (BPH) with symptoms recalcitrant to optimum medical therapy (usually a combination of finasteride and tamsulosin). Therefore, it is not appropriate to refer the patient for this at this stage, where the diagnosis remains uncertain, and the BPH treatment is not yet optimised.
52918
b
Refer for transurethral resection of the prostate
QuestionChoice
This would be the investigation of choice if evaluating for metastatic spread of confirmed cancer. It is done further down the line once a malignancy is diagnosed. In the first instance, the patient needs to be reviewed in the one-stop haematuria service, where biopsies may be taken if a lesion is identified to clinch the diagnosis.
52921
e
CT chest, abdomen and pelvis
QuestionChoice
The presence of voiding lower urinary tract symptoms and microscopic haematuria and the patient's age and occupational history (factory work, with potential exposure to dyes and rubber) should raise suspicion of bladder cancer. Prostate cancer may also present in a similar way. Patients in the one-stop Haematuria Clinic are thoroughly evaluated for a malignant cause of their symptoms, including flexible cystoscopy to evaluate the bladder and prostate, CT or ultrasound scanning of the urinary tree, bloods (such as for the prostate-specific antigen) and urine dipstick testing.
52917
a
Refer to one-stop Haematuria Clinic
QuestionChoice
This patient has a mildly raised PSA and has been diagnosed with BPH. This does not rule out prostate cancer; however, the patient's symptoms can certainly be explained by the presence of a prostatic malignancy but this is less likely given the presence of microscopic haematuria and the history of factory work. Referral to a one-stop haematuria service is the first step in the management of this presentation due to the presence of haematuria, which requires a dedicated set of investigations. An MRI prostate may be requested further down the line if there is concern that there is prostate cancer if no explanation for his symptoms are identified during the one-stop service or as a first-line investigation for suspected prostate cancer.
52920
d
MRI prostate
QuestionChoice
Prostate-specific antigen (PSA) has high sensitivity but low specificity for prostate cancer. It can be raised in other conditions, such as benign prostatic hypertrophy; thus, alone it cannot be used to diagnose prostate cancer. Furthermore, a negative PSA does not rule out malignancy of the prostate or elsewhere in the urinary tract. Given the continuation of this patient's urinary symptoms after pharmacological management and the presence of haematuria, malignancy should be ruled out in a dedicated one-stop Haematuria Clinic.
52919
c
Repeat prostate-specific antigen
Concept
Chapter
# Summary

Bladder cancer, primarily characterised by transitional cell carcinoma, is the 11th most common cancer in the UK. Key risk factors vary by subtype and include smoking, exposure to aromatic amines, schistosomiasis infection, long-term catheterisation, and the presence of other types of bladder cancer. The hallmark sign is visible haematuria, along with potential systemic symptoms like weight loss and night sweats, and local symptoms such as UTIs and hydronephrosis. The disease primarily metastasises to the lungs, liver, and bone. Diagnosis involves various investigations including urine dip, CT urogram, flexible cystoscopy, and other imaging studies. Management strategies differ based on whether the cancer is muscle invasive or non-muscle invasive, and can include surgery, chemotherapy, immunotherapy, and radiotherapy.

# Definition

Bladder cancer is a malignant growth within the urinary bladder. The most common histological subtype in developed countries is transitional cell carcinoma, accounting for 90% of all bladder cancers, followed by squamous cell carcinoma and other types.

# Epidemiology

Bladder cancer is the 11th most common cancer in the UK. In developed countries, 90% of bladder cancers are transitional cell carcinomas, while the remainder are primarily squamous cell carcinomas.

# Aetiology

Risk factors vary depending on the histological subtype of the cancer:

## Risk factors for Transitional Cell Carcinoma

- Smoking
- Exposure to aromatic amines (employed in rubber, dyes, and chemical industry)
- Use of Cyclophosphamide

## Risk factors for Squamous Cell Carcinoma

- Schistosomiasis infection
- Long-term catheterisation (10+ years)

## Risk factors for Adenocarcinoma

- Presence of other types of bladder cancer
- Local bowel cancer

## Risk factors for Small Cell Bladder Cancer

- Association with other types of bladder cancer

# Signs and Symptoms

The cardinal sign of bladder cancer is **painless visible haematuria.** Clinical features can be grouped into local and systemic categories, with the severity depending on the advancement of the disease.

Local features:
- Painless haematuria
- Recurrent UTIs
- Hydronephrosis

Bladder cancer can also invade adjacent structures such as the obturator nerve, resulting in neuropathic pain on the medial thigh.

Systemic features:
- Unintended weight loss
- Night sweats

# Differential Diagnosis

Bladder cancer should be differentiated from other conditions presenting with similar symptoms:

- Urinary tract infection: Characterised by dysuria, frequency, urgency, lower abdominal pain and potentially haematuria.
- Kidney stones: Present with colicky flank pain, haematuria, and potentially UTI symptoms.
- Benign prostatic hyperplasia: Symptoms include nocturia, urinary hesitancy, and a weak stream. There may be microscopic haematuria but typically no gross haematuria.
- Interstitial cystitis: Characterised by chronic pelvic pain, urinary frequency, and urgency in the absence of an identifiable cause.

# Investigations

Initial bedside investigations include a urine dipstick test to identify haematuria. If there's doubt over the presence of true haematuria, a lab sample can be sent (urine MCS) to confirm the presence of red blood cells, as well as casts (if there are dysmorphic red blood cells it suggests bleeding is glomerular in nature and not from lower urinary tract).

Imaging investigations are crucial for diagnosis and staging:

- CT Urogram: Contrast is injected into a vein, filtered by the kidney, and excreted into the urinary collecting system. A CT scan then visualises the urinary tract to identify filling defects indicating a tumour.

- Flexible cystoscopy: Allows for visualisation of any defects in the bladder and the morphology of any suspicious lesions. If a lesion is identified, a biopsy can be taken.

Further staging investigations may include radiographs, CT scans, MRI scans, and bone isotope scans.

## 2 week wait referral criteria

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for bladder cancer:

- If they are aged 45 years and over and have:
	- Unexplained visible haematuria without urinary tract infection, or
	- Visible haematuria that persists or recurs after successful treatment of urinary tract infection.
- If they are aged 60 years and over and have unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test.
- Consider non-urgent referral for bladder cancer in people aged 60 years and over with recurrent or persistent unexplained urinary tract infection.


# Classification

Bladder cancer can be classified according to stage and grade, utilising the WHO TNM system. The staging system is based on localised tumour invasion (T), presence of lymph nodes (N), and distant disease (M). Both imaging modalities and pathological specimens are used for staging, with a key objective being differentiation between muscle invasive and non-muscle invasive bladder cancer.

The grade of cancerous cells can be histologically graded from 1-3, with 1 being the least aggressive and 3 the most aggressive.

When it comes to classification and staging the most important aspect is whether the tumour is non-invasive or muscle-invasive as this determines treatment:

-	Non-muscle invasive: Tis (non-invasive, in situ), Ta – non-invasive, T1 – tumour invades inner lining and connective tissues. 
-	Muscle invasive: T2 (tumour invades muscle), T3 (invades perivesical fat and LN), T4 (metastatic spread). 


# Management

The management of bladder cancer is categorised based on whether the cancer is muscle invasive or non-muscle invasive.

## Non-muscle invasive bladder cancer

This includes stages CIS, Ta, and T1 and is managed with:
- Surgery: Transurethral resection of the bladder tumour (TURBT) is the gold standard.
- Chemotherapy: The bladder can be instilled with chemotherapeutic agents such as Mitomycin C (single dose if low risk, 6 week course if intermediate risk).
- Immunotherapy: BCG immunotherapy can be instilled into the bladders of patients with high-risk non-muscle invasive cancers or carcinoma in situ (CIS).
- If there is high-risk muscle non-muscle invasive cancer/CIS a radical cystectomy may still be considered.

## Muscle invasive bladder cancer

This includes any stage from T2 and above. The gold standard treatment is a radical cystectomy with urinary diversion, with options including an ileal conduit, neo-bladder, or Mitrofanoff procedure. Non-surgical treatment options include radiotherapy and chemotherapy, which can be used in both curative and palliative capacities.

# NICE Guidelines

[Click here for the NICE Guidelines](https://www.nice.org.uk/guidance/ng2)

[NICE CKS - Urological cancers - recognition and referral
](https://cks.nice.org.uk/topics/urological-cancers-recognition-referral/)
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791
Bladder cancer
Topic
22
Urology
10644
In patients over 50 with urinary symptoms and haematuria, a referral to the haematuria clinic is required for evaluation of potential bladder or prostate cancer.
A 73-year-old man is referred to the Urology Clinic with a 3-month history of voiding  symptoms. He finds he has intermittent poor stream and hesitancy when passing urine. He denies any weight loss, fatigue or night sweats and any other urinary symptoms. He is a retired factory worker. His GP had detected an enlarged prostate and a mildly raised prostate-specific antigen 3 months ago and diagnosed him with benign prostatic hypertrophy. He has been taking tamsulosin since but his symptoms are unchanged. His urine dipstick in clinic today is positive for blood.

Which of the following is the best next step in the management of this patient?
a