Bladder cancer
Bladder cancer, most often urothelial (transitional cell) carcinoma, is the most common genitourinary malignancy and classically presents as painless gross hematuria in a smoker. Diagnosis requires cystoscopy with biopsy, and management is staged by depth of invasion, from intravesical therapy for non-muscle-invasive disease to radical cystectomy or systemic chemotherapy for muscle-invasive or metastatic disease.
- Topic reviewThe full article, organized the way the exam asks it.
- ABIM-format MCQsVignettes with an explanation for every wrong answer.
- Key factsThe numbers and thresholds worth memorizing, up front.
- AI tutorMedBrain answers the question you're stuck on.
What this article covers
- Overview
The most common genitourinary malignancy: bladder cancer is the fifth most common malignancy overall in the United States and the most common cancer of the urinary tract.
- Epidemiology
Fifth most common cancer in the United States and the most common malignancy of the genitourinary tract.
- Risk factors
Cigarette smoking: the single strongest and most common risk factor.
- Pathophysiology
Urothelial carcinogenesis from carcinogen exposure: tobacco smoke and aromatic amine/hydrocarbon carcinogens are excreted in urine and directly contact the transitional epithelium, driving…
- Clinical features
Painless gross hematuria: the most common presenting symptom, often intermittent over weeks to months rather than continuous, and this painless, intermittent pattern is a key discriminator from more painful causes of hematuria.
- Differential diagnosis
Urinary tract infection: urgency and frequency, but typically with dysuria and fever, and hematuria resolves with antibiotic treatment, unlike the persistent hematuria of bladder cancer.
- Diagnosis
Bladder cancer is confirmed by cystoscopy with biopsy, the gold-standard diagnostic test, which directly visualizes the tumor, allows tissue sampling for histologic subtype and grade, and evaluates…
- Management
First, perform TURBT for both staging and initial treatment of any newly diagnosed bladder tumor; the depth of invasion found at resection dictates every subsequent step.
- Complications
Local recurrence across the urothelium: the entire carcinogen-exposed urothelial field remains at risk, making recurrence common even after complete resection of the index tumor.
- Prognosis
Excellent for non-invasive disease: five-year survival is 90% to 95% for non-muscle-invasive bladder cancer.
- Prevention
Smoking cessation is the single most effective preventive measure, since cigarette smoking is the dominant modifiable risk factor; counsel every current smoker to quit and offer pharmacologic cessation support.
Read the whole article
Subscribing to Internal Medicine opens every article, the full question bank and MedBrain, on the web, iPhone and Android.
Related articles
- Renal cell carcinoma
Renal cell carcinoma is the most common kidney cancer, arising from renal tubular epithelium (most often clear cell), and is now diagnosed incidentally on imaging in most patients rather than through the classic triad of flank pain, hematuria, and mass. Contrast CT or MRI showing an enhancing solid renal mass is usually sufficient to diagnose and stage disease, and treatment is surgical for localized tumors versus tyrosine kinase inhibitors and immune checkpoint inhibitors for metastatic, chemo- and radio-resistant disease.
- Prostate cancer
Prostate cancer is the most commonly diagnosed cancer in men, usually found through an elevated PSA in an asymptomatic patient, with risk stratified by PSA, Grade Group (Gleason score), and TNM stage. Localized low-risk disease is often managed with active surveillance, while higher-risk and metastatic disease require radiation, surgery, or androgen deprivation therapy escalated through castrate-sensitive and castrate-resistant phases.
- Approach to hematuria
Hematuria is present in urine when at least 3 erythrocytes per high-power field are seen on microscopy, and the first branch point is glomerular versus nonglomerular bleeding, based on erythrocyte morphology and casts. Gross hematuria always requires urologic evaluation and cystoscopy, asymptomatic microscopic hematuria is risk-stratified by American Urological Association criteria to select repeat testing, imaging, or cystoscopy, and glomerular hematuria is treated with disease-specific immunosuppression after biopsy.
- Nephrolithiasis
Nephrolithiasis affects 7-11% of the US population, most often as calcium oxalate stones, and presents as colicky flank pain radiating to the groin with hematuria. Noncontrast CT confirms the diagnosis and stone size drives management: hydration, NSAID/opioid analgesia, and alpha-blocker expulsive therapy for stones under 10 mm, urologic intervention for larger, infected, or obstructing stones.
- Schistosomiasis
Schistosomiasis is a trematode infection acquired by cercarial penetration of skin during freshwater contact, causing intestinal and hepatosplenic disease with Schistosoma mansoni or S. japonicum, or urinary tract disease with S. haematobium. Diagnosis rests on demonstrating eggs in stool or urine or a positive serology, and praziquantel is the treatment for every species.