What are the key symptoms and risk factors for bladder cancer that I should be aware of in my patients?

Key symptoms of bladder cancer to be aware of in patients include visible (macroscopic) haematuria, which is the most common presenting symptom and should prompt urgent referral especially in patients aged 45 years and over without urinary tract infection (UTI), or if haematuria persists or recurs after UTI treatment NICE CKS,NICE NG12. Non-visible (microscopic) haematuria accompanied by dysuria or raised white cell count in patients aged 60 and over also warrants suspicion and referral NICE CKS,NICE NG12. Other urinary symptoms that may raise concern include persistent bladder or urethral pain, voiding difficulties, chronic urinary retention, and recurrent or persistent unexplained UTIs, particularly in patients aged 60 and over NICE CKS,NICE NG12,NICE CKS.

Risk factors for bladder cancer include smoking, which is the most significant modifiable risk factor, occupational exposure to carcinogens (such as aromatic amines), chronic bladder irritation or inflammation (including recurrent UTIs and bladder stones), previous pelvic radiation or cancer surgery, and neurogenic lower urinary tract dysfunction with long-standing complications [1,4, Dobruch et al. 2016]. Age is also a key risk factor, with incidence increasing in older adults, particularly those over 45 years NICE CKS,NICE NG12. Men have a higher incidence than women, but women often present with more advanced disease Dobruch et al. 2016. Chronic exposure to carcinogens leads to urothelial cell mutations, contributing to cancer development Lenis et al. 2020.

In patients with neurogenic bladder conditions, there is an increased risk of bladder cancer, especially with a long history of neurogenic lower urinary tract dysfunction and recurrent infections NICE CG148. Persistent or recurrent haematuria in these patients should prompt consideration of bladder cancer.

Overall, the presence of unexplained visible haematuria, persistent or recurrent haematuria after UTI treatment, non-visible haematuria with urinary symptoms in older adults, and recurrent UTIs in older patients are key clinical triggers for suspecting bladder cancer and warrant urgent or non-urgent referral depending on the clinical context NICE CKS,NICE NG12,NICE CKS. Smoking cessation and lifestyle advice should be part of patient management to reduce risk NICE CKS.