A demented 75-year-old man presents with decreased voiding for three days. His caregiver says he has not complained of abdominal or back pain, fever, weight loss, or night sweats.
Here is what you see on the ultrasound. What is the diagnosis?
Diagnosis: Bladder Cancer
Bladder cancer is the most common malignancy of the urinary tract and the fourth most common cancer in men in the United States. (Urol Oncol 2014 Apr 15. doi: 10.1016/j.urolonc.2013.12.005. [Epub ahead of print].) Affecting 74,690 new patients each year, transitional cell (urothelial) cancer is the most common (90%) histological form. (American Cancer Society; http://bit.ly/1mHdYDm.)
It is also the 10th most common cause of death from solid tumor cancer in this country. (CA Cancer J Clin 2012;62:10.) The risk factors for bladder cancer are well documented, and include chronic infection amoebae resulting in schistosomiasis, exposure to chemical carcinogens found in tobacco, exposure to cyclophosphamide, a history of pelvic radiation, environmental exposure to aromatic amines, and spinal cord injuries with chronic indwelling catheter placement. (Practitioner 2014;258:23.) Other known risk factors include older, white men and those with a family history of bladder cancer.
The most common clinical presentation of bladder cancer is painless hematuria. Some have argued that hematuria in a person 40 years or older should be considered bladder cancer until proven otherwise. (American Urological Association Guideline: Diagnosis, Evaluation and Follow-up of Asymptomatic Microhematruia in Adults, May 2012; http://bit.ly/1meXFci.) Urologic cancers are a very rare etiology of microscopic hematuria. (J Urol 1992;148:788.) The clinical presentation of bladder cancer depends on how advanced the disease is at presentation. Pseudohematuria can occur with medications such as pyrimidine, vegetable dyes, beets, myoglobin, or urates. More advanced diseases, however, can present with symptoms resulting from large local tumor invasion to metastases in the lungs and bones.
The diagnostic evaluation when urothelial cancer is suspected should include evaluation of the entire urinary tract if hematuria is determined not to be from a glomerular etiology. (Urology 2003;61:109.) Deformed RBCs and RBC casts are markers of intrinsic renal disease, while normally-formed RBCs are more indicative of an extrinsic source of bleeding. This evaluation should include urine cytology with urine tumor markers, direct visualization with cystourethroscopy (including fluorescence staining), and imaging to evaluate the upper tracts. MRI may be used as an alternative in patients with a known contrast allergy (World J Radiol 2014;6:344), while ultrasound is inadequate to evaluate bladder masses fully. (Ann R Coll Surg Engl 2002;84:203.)
The initial diagnosis of bladder cancer is with cystoscopy, which can determine local tumor size, determine if muscle has been invaded, and allow for initiating therapy via resection. (Eur Urol 2002;41:178.) CT imaging of the abdomen and pelvis with contrast is necessary to determine evidence of tumor extension and upper tract involvement. (Radiology 1992;185:741.) Scans are also used to identify metastases of the lymph nodes, retroperitoneal area, viscera, lung, and bones. Patients with confirmed or suspected bony metastasis may benefit from a bone or PET scan.
The treatment for bladder cancer depends on how advanced the disease is. The regimen includes some combination of chemotherapy (typically a cisplatin-based combination), surgical resection, and radiation therapy. (N Engl J Med 2012;366:1477; Eur J Surg Oncol 2014 Mar 28; doi: 10.1016/j.ejso.2014.03.006 [Epub ahead of print].) Most (65%) of these tumors, however, are found early with non-muscle invasion so are treated only with cystoscopic resection. (Ann Intern Med 2010;153:461.)
Survival depends on tumor staging (TNM: tumor, node, metastasis). A bladder cancer diagnosis is not one most emergency physicians frequently make, but painless hematuria may be and should prompt a recommendation for follow-up in patients with no known etiology. This patient had a known diagnosis of advanced bladder cancer. A three-way Foley catheter was placed, and large clots were evacuated. The patient's urologist was consulted, and close outpatient follow-up was arranged.
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