👒 Bladder CA

Haematuria History #

True Haematuria or Not #

  • Exact Color: Dark tea color (OJ)
  • Exclude Pseudohaematuria:
    • Itching & steatorrhoea
  • Factitious Haematuria:
    • Munchausen’s syndrome, narcotic seeking behavior

Past History #

  • Bleeding diathesis & other bleeding manifestations

Relation of Gross Haematuria to Urinary Stream #

  • Initial (urethra distal to urogenital diaphragm)
  • Total (bladder proper or upper urinary tract)
  • Terminal (trigone/ bladder neck of prostatic urethra)

Painless or Painful #

  • Painless:
    • Malignant but can cause pain due to clot colics
  • Painful:
    • Urinary tract infection or calculus, papillary necrosis, passage of clots, obstruction, loin-pain haematuria syndrome, glomerulonephritis

Clots #

  • Indicate non-glomerular bleeding
  • Large, thick, irregular clots - bladder
  • Small, linear clots - upper tract
  • Passage of tissues

Associated Symptoms #

  • LUTS
  • Fever, chills & rigors with loin pain or suprapubic pain
  • Any loin pain with self-felt loin lumps (Classic triad of RCC 10% - haematuria+loin pain+loin mass)
  • Tissue passage
  • Vaginal or penile discharge, sexual activity
  • Presence of urinary catheter
  • Relation to menstruation (endometriosis)
  • Anemic symptoms

GU History #

  • History of BPH, stone disease
  • (Hx of GU cancers)
  • Hx of instrumentation
  • Hx of pelvic irradiation

Aetiology for Malignancies #

  • Smoking
  • Occupational exposure to dye stuffs and rubber compounds
  • Hx of travel to middle east countries (Schistosoma haematobium)
  • Family history malignancy (bleeding diathesis + renal disease)

Metastatic Features #

  • Fitness for Sx

PMHx- #

PSHx- #

Drug Hx- #

  • Antiplatelets or anticoagulants, cyclophosphamide

SHx- #

  • Job(risk factors)/family
  • Smoking/alcohol
  • Disability/concerns

Examination #

General #

  • Anemia/plethora
  • Facial oedema/ periorbital oedema, rather than ankle edema suggest renal pathology
  • Unilateral or bilateral ankle edema- think of Iliac vein compression in unilateral edema
  • Bone tenderness
  • Muscle weakness
  • Malignant cachexia- anaemia asthenia anorexia
  • Ask for BP

Abdomen #

  • Palpable suprapubic mass- distended bladder, anterior wall bladder tumor
  • Ballotable renal mass
  • Hepatomegaly
  • Ascites
  • DRE & genital Ex (non-reducing left varicocele)

Summary #

This 60 yrs old ASA 2, MET score >4, male patient with episodic visible haematuria over 3 months associated with occasional clots & passage of tissues. He has mild irritative LUTS. He is a smoker & works at a rubber processing center. His examination findings were unremarkable.