The Hematuria Cancer – Every Athlete’s Nightmare.

It can be reported by the patient, which is macroscopic hematuria, and when it is not visible through the eye and detected in the microscopic examination on dipstick testing of urine then it is microscopic hematuria. This indicates that bleeding can be occurring from anywhere in the renal tract. It’s a real nightmare for athletes or anyone who work out in the same quantity. This is also known as “The Hematuria Cancer – Every Athlete’s Nightmare.”  Hematuria can be visible from the naked eye.

Microscopy shows that normal individuals have occasional red blood cells (RBC) in the urine (up to 12 500 RBC/mL). The detection limit for dipstick testing in urine for the presence of RBC is 15–20 000 RBC/mL, which is sufficiently sensitive for the detection of blood in the urine. 

However, it is also seen that dipstick tests are also seen as positive in the presence of free hemoglobin or myoglobin.

Urine microscopic examination can be valuable for confirming haematuria and helps in establishing the cause of bleeding in the urine. Other causes of red or dark urine may sometimes be confused with haematuria but produce negative dipstick tests and microscopy. 

True positive dipstick tests for the presence of blood may occur during menstruation in females, infection, or strenuous exercise in athletes, but if haematuria persists, then it requires further investigation to exclude malignancy. 

Glomerular bleeding is characteristic of inflammatory, destructive, or degenerative processes that disrupt the glomerular basement membrane (GBM) to cause microscopic or macroscopic haematuria. In glomerulonephritis, one or more other features of the ‘nephritic syndrome’ may be present, but the full syndrome is rare. Macroscopic (visible) haematuria is more likely to be caused by tumors.

Severe infections or renal infarction can also cause macroscopic haematuria, usually accompanied by pain.

Causes of hematuria cancer: –

In kidney: –

  • Clotting disorders
  • Cyst
  • Tumor
  • Vascular malformation
  • Glomerular disease inflammatory degenerative
  • Interstitial disease
  • Infraction
  • Infection

In ureter:-

  • Tumor
  • Stones

In bladder:-

  • Infection
  • Tumor
  • Trauma

Other causes:-

  • Enlarged prostate in old men
  • Period in women
  • Prostate infection
  • Bladder cancer in smokers
  • Drugs used for blood thinning
  • Drugs used to reduce swelling
  • Heavy work

When blood is found in the urine, the health care or doctor wants to make sure whether the patient is having any serious disorder or not, which includes cancer of kidney or bladder. While cancer of urology is not commonly found but still 2-3 in 100 patients are diagnosed with urological cancer.

Risk factors which increase the chances of Hematuria cancer: –

Age factor:- If age is more than 35 years.

Chronic smoker:- If the patient is a chronic smoker in the past or present

Factory worker:- If the patient works in the chemical factory

Prior urological disorder:- If the patient has a prior urological disorder

Poor pelvic radiation:- If the patient had poor pelvic radiation for cancer

Suffering from urinary tract infection:- If the patient has pain or suffering from urinary tract infection in which the patient has a problem in voiding urine

Urinary infection:- If the patient has a chronic urinary infection

Blood in the urine (haematuria) may be the only indication of cancer and other pathology in the urinary tract. Haematuria may be intermittent or persistent. 

If the patient experiences pain with the presence of blood in urine, the characteristics of the pain, which include location, may help to detect the cause of the bleeding. If there is a malignant cause for the haematuria than the patient will not have any pain.

Urinary bladder cancer:-

Bladder cancer is the commonest urological malignancy found in India and the second most common genitourinary malignant disease in the world. Males are commonly affected more than females with the ratio of M: F= 2.4:1, and urinary bladder cancer occurs mostly in the elderly with median age persons who are about 60 to 70 years.

Causes of bladder cancer and risk factors:-

Cigarette smoking is the single most important environmental factor which is responsible for bladder cancer, other risk factors which are responsible for bladder cancer are:-

  • Chemical exposure to aromatic amines
  • Aniline dyes in industries
  • Analgesic abuse 
  • Schistosoma infestation in certain regions of the world

Pathology of urinary bladder cancer:-

Carcinoma of bladder is a heterogeneous disease that presents as superficial, muscle-invasive or metastatic disease. Morphologically, most of the bladder cancer, about 70% is exophytic papillary tumors confined to mucosa (Ta) or invade submucosa (T1). About 50% to 70% of superficial tumors recur, and 5% to 20% of them progress to invasive disease.

Histopathologically, most bladder cancers are transitional cell carcinomas, which were about 90% to 95%. Low-grade tumors have a high local recurrence rate but usually do not invade muscularly. High-grade superficial tumors have a high propensity to transform into invasive tumors. All invasive tumors are high grade.

Clinical features of urinary bladder cancer:-

Most of the patients with urinary bladder cancer present themselves with painless hematuria, which are about 80-90%. Along with this, the patient also presents themselves with unexplained urinary frequency or difficulty in voiding urine. 

Lower urinary irritative and obstructive symptoms may be the sole presenting symptoms in the absence of haematuria. 

The currently accepted staging classification of primary bladder cancer is as follows:

  • Ta: Non-invasive papillary carcinoma
  • T1: Invasion of lamina propria
  • T2: Invasion of muscularis propria
  • T3: Invasion of perivesical tissues
  • T4: Invasion of adjacent organs or pelvic/abdominal wall

Other symptoms of bladder cancer include:-

  • Blood in the urine or blood clot present in the urine
  • Frequent urging for urine
  • Pain with burning sensation while passing the urine
  • Frequent urging to pass urine in the whole night
  • Feeling to pass the urine with not able to void the urine
  • Lower backache at one of the body

Investigation for urinary bladder cancer:-

Most of the time, the bladder is detected when the patient comes to the doctor with the complaint of blood in the urine, which is called hematuria.

General urine test is not considered as a specific diagnosis for bladder cancer as hematuria is often present in many of the disease conditions like a kidney stone or infection and which does not include cancer.

Cystoscopic examination of the bladder and pathological evaluation of the resected lesion form the cornerstone of diagnosis. Transurethral resection of the bladder tumor (TURBT) is the most important test which is used for judging the depth of tumor penetration in the bladder. The inclusion of muscle in biopsy is essential.

An important component of the work-up is an examination under anesthesia after TURBT to evaluate the presence of residual induration and mass. CECT of chest, abdomen, and pelvis and urine cytology are the other investigations that are done at initial evaluation and follow-up.

Other effective investigation methods for hematuria cancer: –

  • Urine
  • Blood for urea, serum electrolyte, and hemoglobin
  • CT scan
  • Magnetic resonance
  • IVU or ultrasound scanning
  • Cross-sectional imaging
  • Cystourethroscopy
  • Bimanual examination under general anesthesia 

How to know that cancer had spread in the body:-

Sometimes the first symptoms of the urinary bladder appear late; at the time, cancer has spread to another part of the body. In that situation, the symptoms which the patient will give depend upon the metastasis (spread) of the tumor in the body. 

If cancer has spread to the lungs than the patient will complaints of cough with difficulty in breathing.

It is spread to the liver, then the patient will receive complaints of abdominal pain with the yellowish color of the skin (jaundice).

If it has spread to the bone, then the patient will complaint of bone pain and the patient is prone to pathological fracture.

Other symptoms which the patient present are- loss of appetite, pain in the back or pelvic region, and weight loss.

Treatment for urinary bladder cancer: –

Treatment of non-muscle invasive disease

TURBT is the standard of care for superficial bladder cancers. The goal of TURBT in Ta/T1 bladder tumors is to make the correct diagnosis and remove all visible lesions. These tumors are classified as low or high risk based on tumor grade, size, number, and invasion of lamina propria. 

Based on their risk, stratification patients receive either intravesical chemotherapy or Bacillus- Calmette Guerin. They are followed up with serial cystoscopies after treatment to monitor for recurrence.

Treatment of muscle-invasive disease

Radical cystectomy is the preferred treatment for invasive bladder cancers in patients whose medical condition allows a major surgical procedure. Pelvic lymphadenectomy has routinely proceeded as a piece of radical cystectomy for bladder malignant growths.

Such patients may also benefit from neoadjuvant chemotherapy using either the MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin) or gemcitabine-cisplatin combinations. Bladder conservation can be done in selected patients with multimodality treatment involving neoadjuvant chemotherapy, followed by concurrent chemoradiation.

Chemotherapy for metastatic bladder cancer

The common sites of metastatic spread include lymph nodes, lung, liver, and bones. Chemotherapy is the standard therapy for patients with metastatic bladder cancer in good performance status. The gemcitabine-cisplatin combination is often used.

Final word

If you find any changes in the symptoms after taking the treatment for bladder cancer, it is essential to talk to the doctor to clarify all the doubts which come in mind. 

Your doctor will ask you questions regarding the symptoms like when they started appearing, as this will help the doctor for diagnosis of the condition you are suffering. 

If the cancer is diagnosed in an advanced stage at that time, the main treatment for the cancer is relieving the symptoms, this treatment is known as a palliative, or supportive care which is started as the diagnosis of cancer is confirmed. 

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