History
The signs and symptoms of urethral cancer vary and are neither diagnostic nor pathognomonic. Generally, the onset is insidious, and symptoms are usually more attributable to benign stricture disease (ie, bladder outlet obstruction, overflow incontinence) rather than malignancy (ie, perineal pain, hematuria). In fact, in both sexes, cancer may be completely asymptomatic except for a hard nodular area in the perineum, labia, or along the course of the penis.
The interval between the onset of symptoms and diagnosis may be as long as 3 years because of misdiagnoses and failure by the patient to seek medical consultation. Male patients may initially be diagnosed with more common causes of symptomatology such as benign prostatic hyperplasia (BPH) or urinary tract infection. Further investigation should be performed if a suspected urinary tract infection recurs quickly or if symptoms fail to resolve.
Remember also that these tumors have a propensity to be highly advanced locally at the time of diagnosis. A raised index of suspicion is advisable if an elderly man presents with stricture disease, particularly if symptoms are more consistent with malignancy or local extension (ie, urethral fistulae, abscess formation, and necrosis).
Although stricture disease is less common in women, chronic inflammation or irritation in the form of infection, urethral polyps, caruncles, or urethral diverticula can give clues to the presence of urethral carcinoma. [14]
Diminished stream, straining to void, and other obstructive voiding symptoms are common. Although these are often the symptoms of benign stricture disease or BPH, a neoplasm may be concealed by the presentation of a routine stricture. Maintain a high index of suspicion in patients with a history of urethral stricture disease and keep a vigilant eye over the proceeding cytological analysis, radiographic imaging, and cystoscopy.
Frequency, nocturia, itching, dysuria, and other irritative voiding symptoms are reported in association with carcinoma in situ. Incontinence is generally overflow incontinence caused by bladder outlet obstruction due to urethral stricture disease. However, severe urgency may progress to urge incontinence and distortion of the urethral anatomy in females and may lead to stress urinary incontinence.
Other signs and symptoms include:
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Urinary retention from progressive urethral stricture disease
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Hematuria, urethral or vaginal spotting
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Purulent, foul-smelling, or watery discharge
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Hematospermia
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Perineal, suprapubic, or urethral pain
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Dyspareunia
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Swelling
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Tenesmus
Physical Examination
Early evaluation should include a thorough physical examination, including a complete genital and rectal examination, with palpation of the entire urethra and perineum. Care should be taken to palpate along the entire urethra and regional lymph nodes, as local invasion occurs early in the disease. Presence of lymphadenopathy should be noted for later surgical consideration. The meatus should be examined closely with attention to mucosal irregularities or bloody discharge.
Sexually transmitted diseases increase the risk of urethral cancer and should be identified routinely during the examination. The perineum should be examined for abscesses and fistulae, as these may be a sign of locally advanced disease.
Bimanual examination should be performed as well since it allows the clinician to estimate the extent of local invasion and involvement of the bladder.
Physical examination findings include:
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Urethrocutaneous fistula
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Urethrovaginal fistula
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Periurethral abscess or areas of tissue necrosis
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Recurrent urinary tract infection
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Penile or vaginal lesions
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Lymphadenopathy
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Palpable mass along the course of the urethra
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Male urethral anatomy from most proximal to distal. Shown is the prostatic urethra (from bladder neck to the urogenital diaphragm [UGD]), membranous urethra (traversing the UGD), bulbous urethra (from the UGD to the penoscrotal junction), and the penile or pendulous urethra (from the penoscrotal junction traversing distally) with its boat-shaped most distal aspect, the fossa navicularis. Note the adjacent structures of the corpus cavernosum, bladder, prostate, pubic symphysis, perineum, and scrotum, which are sites of local extension and often are excised en bloc.
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(A) Normal anatomy. Sagittal T2-weighted image labelling the prostatic, membranous, and bulbous segments of the normal male urethra. (B) Normal anatomy. Illustration of the normal female urethra in axial cross-section. (C) Normal anatomy. Axial T2-weighted image of a normal female urethra. Note the hypointense signal of the mucosa and outer muscular layer and hyperintense submucosa. Image used with permission from Del Gaizo A et al, Magnetic resonance imaging of solid urethral and peri-urethral lesions. Insights Imaging. Aug 2013;4(4):461-9. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3731464/.
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Illustration of the male urethra in the sagittal plane highlighting the percentage of urethral carcinoma by location (1st percentage) and the most common histological subtype in that location (2nd percentage). TCC = transitional cell carcinoma, SCC = squamous cell carcinoma. Image used with permission from Del Gaizo A et al, Magnetic resonance imaging of solid urethral and peri-urethral lesions. Insights Imaging. Aug 2013;4(4):461-9. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3731464/.
Tables
Primary tumor (T) |
|
Male penile urethra and female urethra |
|
TX |
Primary tumor cannot be assessed |
T0 |
No evidence of primary tumor |
Ta |
Noninvasive papillary carcinoma |
Tis |
Carcinoma in situ |
T1 |
Tumor invades subepithelial connective tissue |
T2 |
Tumor invades the corpus spongiosum or periurethral muscle |
T3 |
Tumor invades the corpus cavernosum or anterior vagina |
T4 |
Tumor invades other adjacent organs (eg, bladder wall) |
Prostatic urethra |
|
TX |
Primary tumor cannot be assessed |
T0 |
No evidence of primary tumor |
Ta |
Noninvasive papillary carcinoma |
Tis |
Carcinoma in situ involving the prostatic urethra or periurethral or prostatic ducts without stromal invasion |
T1 |
Tumor invades urethral subepithelial connective tissue immediately underlying the urothelium |
T2 |
Tumor invades the prostatic stroma surrounding ducts either by direct extension from the urothelial surface or by invasion from prostatic ducts |
T3 |
Tumor invades the periprostatic fat |
T4 |
Tumor invades other adjacent organs (ie, extraprostatic invasion of the bladder wall, rectal wall) |
Regional lymph nodes (N) |
|
NX |
Regional lymph nodes cannot be assessed |
N0 |
No regional lymph node metastasis |
N1 |
Single regional lymph node metastasis in the inguinal region or true pelvis or presacral lymph node |
N2 |
Multiple lymph node metastases in the inguinal region or true pelvis or presacral lymph node |
Distant metastasis (M) |
|
MX |
Distant metastasis cannot be assessed |
MO |
No distant metastasis |
M1 |
Distant metastasis |
Stage |
T |
N |
M |
Stage 0a |
Ta |
N0 |
M0 |
Stage 0is |
Tis |
N0 |
M0 |
Stage I |
T1 |
N0 |
M0 |
Stage II |
T2 |
N0 |
M0 |
Stage III |
T1 |
N1 |
M0 |
T2 |
N1 |
M0 |
|
T3 |
N0 |
M0 |
|
T3 |
N1 |
M0 |
|
Stage IV |
T4 |
N1 |
M0 |
Any T |
N2 |
M0 |
|
Any T |
Any N |
M1 |
