A 56-year-old male smoker comes in to see you with his wife. He is worried as he has noticed bright red blood when he passes urine. He used to work in a rubber factory. His wife also thinks that he has been more tired than usual over the last couple of months. He has no discomfort when he passes urine but complains of a dull aching sensation in his lower abdomen.

1. What is the most likely diagnosis?
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Although other causes of haematuria will need to be excluded, bladder cancer would be the most likely diagnosis given the history of smoking and working in a rubber factory. These are well-known risk factors for developing bladder cancer.


Bladder cancer affects around 1:5000 people and is three times more common in men than in women. 90% are transitional cell carcinomas.


Bladder cancer can present with macroscopic or microscopic haematuria. It can be painless or painful. There may be pelvic or loin pain and symptoms of recurrent UTI. An MSU can usefully exclude a UTI and help in the detection of microscopic haematuria.

2. Name some risk factors for this diagnosis?
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Risk factors for bladder cancer include:

  • Smoking (50% of male and 25% of female bladder cancer cases are thought to be due to smoking)
  • Exposure to aromatic amine (e.g. work in rubber, leather, textile factories)
  • Urinary stasis
  • Schistosomiasis
3. How should the patient be managed?
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If bladder cancer is suspected, a patient should be referred urgently, and diagnosis usually occurs following biopsies at cystoscopy. 80% of tumours are stage T1 (confined to mucosa or submucosa) at diagnosis, and treatment involves transurethral resection of the tumour (TURBT) with intravesical chemotherapy. Prognosis is excellent at this stage, with most patients dying from other causes.


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