Bladder Cancer Differential Diagnoses

Updated: Jan 09, 2020
  • Author: Gary David Steinberg, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Diagnostic Considerations

Any patient with gross or microscopic hematuria should undergo urologic evaluation. Patients with bladder cancer may have spontaneous resolution of gross or microscopic hematuria, which may lull the patient and the clinician into erroneously believing that no significant entity is present.

The presentation in bladder cancer may resemble urinary tract infection (UTI), or the 2 conditions may coexist. Both UTIs and bladder cancer cause hematuria, and bacteriuria occurs in about 50% of patients with squamous cell carcinoma (SCC). UTIs are usually associated with irritative voiding symptoms (eg, dysuria, frequency, urgency). Irritative voiding symptoms may also be caused by carcinoma in situ (CIS) or muscle-invasive bladder cancer; patients with CIS may present with irritative voiding symptoms only.

CIS is often misdiagnosed as a bladder infection and treated as such. Patients with irritative voiding symptoms that do not resolve with treatment for UTI require further evaluation. The investigation should include urine cultures for fungi and tuberculosis, as well as cytology studies.

Cystoscopy in patients with CIS may reveal a characteristic red, velvety appearance that resembles an area of inflammation. In some cases, however, CIS is not visible on gross inspection.

Diagnostic tests include a urine cytology test and/or tests for one of several available bladder cancer markers. These tests are highly sensitive in detecting CIS. Bladder biopsies are needed to firmly establish a diagnosis. Urinary cytology is highly specific for urothelial bladder cancer, with improved sensitivity for high-grade tumors and cytology obtained by bladder wash or barbotage.

Unfortunately, urinary cytology is not especially helpful in early diagnosis of SCCs. Most of these tumors are not diagnosed until they are at an advanced stage.

With small cell carcinoma, the main differential diagnoses are high-grade urothelial carcinoma, lymphoma, and sarcoma. Additionally, metastatic small cell carcinoma should be ruled out based on the available clinical information. Because small cell carcinoma of the urinary bladder is often mixed with urothelial carcinoma and because any presence of small cell carcinoma is justifiable to render the diagnosis, it is important to thoroughly examine the tumor tissue.

Differential Diagnoses