Painless Hematuria Sends 22-Year-Old Man to the Hospital

A 22-year-old man presented for medical assessment in January after noticing blood in his urine. He explained that this had been going on for about 2 weeks, but had not caused any pain.

He told clinicians that he worked in an office and is a non-smoker. He had not been exposed to any chemicals. His family history included hereditary nonpolyposis colorectal cancer and Lynch syndrome, but he was not aware of any other cancers in the family.

Clinicians performed a physical with unremarkable findings. Transabdominal ultrasound revealed an exophytic lesion on the left wall of the bladder. As a result, they sedated the patient to evaluate further, using a flexible white light cystoscopy. This identified a papillary lesion 2 cm in size occupying the left-sided urinary bladder wall.

Surgeons excised the mass via transurethral resection of the bladder tumor, followed immediately by an instillation of mitomycin. Histopathologic assessment of the specimen identified the tumor as a superficial low-grade urothelial bladder tumor pTa G1. Clinicians suggested that the cancer was unlikely to recur or progress, based on the European Association of Urology risk stratification system, so they did not perform a CT scan of the abdomen-pelvis or perform additional genetic evaluations.

The patient returned 3 months later for follow-up; a cystoscopic examination showed no evidence of recurrence. Clinicians placed the patient under regular and intense follow-up through cystoscopy.

Discussion

Clinicians presenting this case of bladder cancer in a 22-year-old man said that this patient’s young age makes the case unique. Diagnosing and treating young patients with bladder cancer can be challenging due to the need for ongoing follow-up of the upper urinary tracts with regular cystoscopies, urinary cytology tests, and pyelographies, they added.

Bladder cancer is the 10th most common cancer worldwide, and its incidence is increasing worldwide, particularly in developed countries, they explained. It is more likely to develop in men and in people older than 55. Well-known risk factors include smoking and occupation-related exposure to chemicals, in particular aromatic amines, the authors noted. In Egypt, where this patient lives, the most common risk factor for bladder cancer is Schistosoma haematobium.

Hematuria is the most common presenting symptom of bladder cancer, and it requires further evaluation using transabdominal ultrasound, cystoscopy, and CT, the authors said.

Indeed, about 80% of patients with bladder cancer present with gross hematuria, which is usually painless and episodic. About 20% of patients present with symptoms of bladder irritation, such as urinary urgency, frequency, and dysuria, which may be associated with carcinoma in situ or muscle-invasive disease.

The case authors described details of a retrospective study involving five patients with a mean age of 24, which noted that young patients with bladder cancer “show more reluctance to comply to the necessary strict follow-up [measures].” All five patients presented with painless hematuria; three were diagnosed with pTa disease, and the remaining two with pT1 and pT2 disease.

Some patients may be predisposed to develop bladder cancer due to underlying genetic factors. Although primary genetic factors have yet to be clearly identified, the authors referenced studies linking MYC, NAT2, and GSTM1 with increased bladder cancer risk.

Generally, a family history of bladder cancer is associated with an increased risk of the disease, with the odds increased nearly seven-fold in relatives of patients who had been diagnosed with bladder cancer at the ages of 40 to 65 and who had a history of smoking compared with never-smokers with a negative family history.

The case authors cited a study of 49 patients younger than 45 that found that urothelial tumors in young patients can be genetically distinguished from those in older patients, based on molecular subtype profiling. Using a Lund subtype-specific immunohistochemistry panel, “the study revealed that 80% of patients had molecular urothelial-like A subtypes, which are characterized by improved recurrent-free survival. However, 10% of patients had molecular urothelial-like D type, which is characterized by high-grade non-muscle-invasive cancers with higher levels of squamous differentiation and p16, E2F3, and Ki-67 expression in addition to Ck20 expression and lower recurrent-free survival,” they wrote.

A retrospective review of clinical aspects of bladder cancer in patients younger than 40 noted tendencies toward nonadvanced stages and low-grade disease that initially presented as less multifocal and was less likely to recur compared with clinical characteristics noted in older patients, the authors said. Other studies have suggested that bladder cancer patients younger than 30 are more likely than those 30 and older to have superficial low-grade and low-stage tumors, as well as a better prognosis.

In addition, another study of bladder cancer patients younger and older than 40 reported comparatively higher likelihood of “low-grade smaller-sized tumors (<3 cm) and higher papillary urothelial neoplasms of low malignant potential” among those younger than 40, with 5-year survival rates of 100% versus 88% in those over 40. However, rates of recurrence-free and progression-free survival were comparable in the younger and older patients, the case authors noted.

Despite the tendency for primary urothelial bladder cancer in young patients to be low-grade and noninvasive, the authors cautioned that “a small percentage may manifest with high-grade invasive tumors that have poor prognosis.” Close follow-up makes management of bladder cancer in younger patients especially challenging, they concluded.

Last Updated December 20, 2021