INFORMATION FOR CANDIDATE:

The next patient in your GP is a 64 year old Mr. Dan

Frydenberg. He has been complaining of one day history
of haematuria. He was completely fine until three days
ago when he had an episode of upper respiratory tract
infection. On examination, his blood pressure was
149/85 mmHg and urine dipstick showed RBCs +++ and
negative protein, WBCs and nitrates.
YOUR TASK IS:
Take any relevant history (do not spend more than 3
minutes)
Ask for any other examination findings if necessary.
Counsel patient about his condition and management
plan.

HOPC:

Mr. Frydenberg noticed passing some blood with his urine yesterday. He did not feel any pain or
discomfort at that time (painless hematuria) but he was very concerned to see the abnormal colored
urine. That was the only time he had haematuria and his urine color returned to normal after that. He
denies any symptoms of hesitancy, slow stream, dribbling, nocturia and urgency. No history of truma.
However, three days ago he was not feeling well due to a sore throat and generalized tiredness which he
thinks it was a simple throat infection. (THE GROSS HEMATURIA AND THE SHORT HISTORY
OF SORE THROAT, MAKE IT UNLIKELY TO BE A CASE OF POST-STERPTOCOCAL GN
WHICH TAKES AT LEAST ONE WEEK TO DEVELOP THE ANTIBODIES)
PHx: Unremarkable (not on any medications including anticoagulants!)
Family History:
His uncle who passed away many years back had bladder cancer.
Social History:
Retired security guard, he worked in an oil refinery, which largely involved supervising trucks and
going on patrols. He smokes one pack per day since high school. Little alcohol over the weekends,
happily married, 3 children. No history of travelling to endemic areas with Schistosomiasis.NKA.
EXAMINATION:
Well looking 64 year old man.
Vital signs: within normal except his blood pressure is 149/85
No pathological findings on physical examination including no masses or tenderness in the abdomen.
PR examination: shows normal size prostate gland with a smooth, rubbery surface and palpable median
furrow.
INVESTIGATIONS:
Urinalysis: is ideal to confirm the presence of red cells in the urine before proceeding with
investigation; however, the nature of the malignant process in the bladder is such that bleeding is
often intermittent and varying in intensity. Therefore, recommend proceeding with investigation
when haematuria is reported in the patients history.
Cystoscopy of the lower urinary tract
CT IV urography or standard intravenous urogram (IVU)
renal tract ultrasound
? Urinary cytology is used by many and has an overall specificity of 96% but a sensitivity of
only 49% when all grades and stages of bladder cancer are examined. However, it is much more
reliable in the diagnosis of high-grade bladder cancer and carcinoma in situ. In a recent study,
urinary cytology was shown to have no added value in the initial routine workup of patients
presenting with haematuria, so that removing cytology resulted in a cost reduction without
compromise of quality
FBE, ESR, U+Es and creatinine
DIAGNOSIS: PAINLESS HEAMATURIA/BLADDER CANCER
Haematuria can be clinically divided into:
A) Painful haematuria is suggestive of:
infection, calculi or kidney infarction.
B) Painless haematuria is commonly associated with:
Trauma, tumours (like prostate, bladder), polycystic kidneys and IgA nephropathy and infection.

A drug history is relevant, especially with anticoagulants and cyclophosphamide. A diet history should
also be considered.
It is worth noting that large prostatic veins, secondary to prostatic enlargement located at the bladder
neck, may rupture when a man strains to urinate.
Bladder cancer is usually transitional cell carcinoma. Symptoms include haematuria; later, urinary
obstruction can cause pain. Diagnosis is by cystoscopy and biopsy. Treatment is with fulguration,
intravesical instillations, surgery, chemotherapy, or a combination.
Risk factors:
Smoking (the most common risk factor, causing 50% of new cases)
Occupational exposure to hydrocarbons, tryptophan metabolites, aromatic amines (aniline dyes,
such as naphthylamine used in the dye industry) and chemicals used in the rubber, electric, cable,
paint, and textile industries
Excess phenacetin/aspirin/caffeine consumption (analgesic abuse)
Long-term cyclophosphamide
Chronic irritation (eg, in schistosomiasis / Bilharziasis or by bladder calculi)
Pathology:
Transitional cell carcinomas (90%), usually papillary carcinomas, which tend to be superficial
and well-differentiated and to grow outward; sessile tumors are more insidious, tending to invade
early and metastasize.
Squamous cell carcinomas, which are less common and usually occur in patients with parasitic
bladder infestation or chronic mucosal irritation. Adenocarcinomas are rare as primary tumors or
sometimes are metastasis from intestinal carcinoma.
DIFFERENTIAL DIAGNOSIS:
1. Acute post-streptococcal glomerulonephritis (unlikely because usually it takes at least one week
to develop the antibocies)
2. IgA nephropathyis a possible diagnoses but it is unlikely in this scenario because usually it
causes glomerular damage with positive protein in urine and the patient has risk factors of Ca
bladder like his occupation, family history and smoking!
MANAGEMENT:
Superficial cancers are treated by endoscopic transurethral resection of the bladder (TURB) and
because of the high risk of recurrence (up to 50%!) followed by instilling mitomycin C into the
bladder post-operatively. Follow-up cystoscopies and voiding cystology need to be arranged at
least every 3 months, later every 12 months!
Fulguration: is the destruction of tissue with a high-frequency electric current applied with a
needlelike electrode.
Intravesical chemotherapy with mitromycin or Bacillus Calmette-Guerin (BCG)
Radical cystoprostatectomy +/- urethrectomy is the preferred method for invasive cancer.
Features to consider in the physical examination of the patient with haematuria(Murtagh):