As a urologist, the last thing I would like to hear from a patient during a clinical visit is: “Doctor, my urine is red, but it doesn’t hurt when I urinate”. Many patients tend to think that if they have hematuria but it doesn’t hurt or itch and there are no physical abnormalities, there is nothing wrong with their health. In fact, if it hurts or itches, it may be a benign disease, but if it is painless hematuria, then it is likely to be a malignant disease, such as urological cancer, especially bladder tumors. This is because painless hematuria is a “unique” sign of bladder tumor.
We usually pay little attention to bladder tumor because it has a strange “temperament”. It is a malignant tumor that is “introverted, hidden and deep”. It does not like to show itself, but always “clenches its tail” and quietly erodes the human bladder. Occasionally, a little bit of tail inadvertently revealed, it hurried to collect up.
Today, we will learn more about the relationship between hematuria and bladder tumor.
Hematuria is very common in clinical practice, but it is not the case that red urine is hematuria, nor is it the case that normal urine color can rule out hematuria. The medical criteria for defining hematuria are: ≥3 red blood cells per high magnification field of view in centrifuged precipitated urine; or more than 1 in non-centrifuged urine; or more than 100,000 in 1 hour urine red blood cell count; or more than 500,000 in 12 hour urine red blood cell count, all indicate abnormal increase of red blood cells in urine, which can also be called hematuria.
According to the amount of blood in the urine.
1, microscopic hematuria urine by centrifugation after sediment microscopy, there are more than 3 red blood cells per high magnification field.
2, naked eye hematuria contains 1m1 blood per 1000ml of urine, which can be seen with the naked eye as slightly blood-colored. However, it is worth noting that not red urine is hematuria. It is reported that the incidence rate of bladder cancer is 17%~18.9% when it is manifested as carnal hematuria and 4.8%~6% when it is manifested as microscopic hematuria.
Generally speaking, patients with hematuria should undergo the following tests to clarify the cause: urine routine, urine red blood cell morphology analysis and urinary ultrasound are the first-line tests: urine routine can qualitatively and quantitatively detect hematuria; urine red blood cell morphology analysis can determine whether glomerular hematuria (e.g. nephritis) or non-glomerular hematuria (e.g. tumor, stone) by the proportion of abnormal red blood cells in urine; urinary ultrasound can determine whether tumor exists in the urinary system. enables preliminary screening for the presence of tumors and stones in the urinary system, and also helps to understand whether the prostate is enlarged and whether there are blood clots in the bladder. If the abnormal red blood cells in the urine account for more than 80% of the glomerular hematuria; if the abnormal red blood cells <20% and homogeneous red blood cells >80% or more, then non-glomerular hematuria is considered. suspected vascular malformation can be done with renal vein ultrasound. Computed tomography (CT) is valuable in diagnosing bladder tumors and in assessing the extent of bladder cancer infiltration (especially to show extra-vesical tumor infiltration). CT can be performed if cystoscopy reveals a tumor with a broad basal tip, a high degree of malignancy, and the potential for muscular infiltration to reveal the extent of infiltration. If the imaging suggests neoplastic bladder, further cystoscopy is indicated. Cystoscopy is used to visualize the entire bladder to clarify the number, size, morphology (papillary or broad-based), and location of bladder tumors as well as abnormalities in the surrounding bladder mucosa, while biopsies of tumors and suspicious lesions can be performed to clarify the pathological diagnosis. Cystoscopy is the only means to confirm the diagnosis of bladder cancer before surgery. In conclusion, the examination of hematuria follows the principles of simple to complex, non-invasive to invasive, both qualitative and localized.
In fact, according to the instinctive mindset of the urologist. There are two “basic points” of diagnosis: one is qualitative and the other is localization. In other words, diagnosis requires thinking about the basic questions of “what is the lesion” and “where is the lesion”. If we cannot qualify, we cannot determine the surgical plan, and if we cannot locate, we cannot choose where to cut.
I. Qualitative diagnosis of hematuria
1.After finding “red urine”, we must first distinguish whether it is true hematuria or pseudohematuria. First of all, hematuria should be distinguished from contaminated urine such as menstruation, uterine vaginal bleeding and hemorrhoid bleeding. Secondly, hematuria should be distinguished from hemoglobinuria, which is bright red or dark red in color, cloudy after oscillation, red precipitation after placement, and a large number of red blood cells on microscopic examination, while hemoglobinuria is obviously different, brownish red or soy sauce in color, not cloudy after oscillation, no precipitation after placement, no red blood cells or only a few red blood cells on microscopic examination, and significantly higher if free hemoglobin of blood is measured. Hematuria also needs to be distinguished from red urine caused by certain drugs, fruits and dyes. This red urine is mostly seen after the use of aminopyrine, Congo red, phenol red, rifampin and other drugs, but there are no red blood cells on microscopic examination, which can be distinguished.
2.The sensitivity of urine exfoliative cytology for detecting bladder cancer is 13%~75%, and the specificity is 85%~100%. The sensitivity is closely related to the malignancy grading of cancer cells. The sensitivity of bladder cancer with low grading is low, on the one hand, because tumor cells are better differentiated and their characteristics are similar to normal cells, so it is not easy to distinguish them, on the other hand, because cancer cells are relatively tightly adhered to each other and not enough cancer cells are shed to urine to be detected, so a negative urine cytology cannot exclude the existence of low-grade uroepithelial cancer; on the contrary, bladder cancer with high grading bladder cancer or carcinoma in situ, the sensitivity and specificity are higher.
3.Urine bladder cancer markers: In order to improve the level of non-invasive detection of bladder cancer, the research of urine bladder cancer markers has received great attention, and the US FDA has approved the use of BTAstat, BTAtrak, NMP22, FDP, ImmunoCyt and FISH for the detection of bladder cancer. Although most urinary bladder cancer markers have shown high sensitivity, their specificity is generally lower than that of urine cytology, and so far, there is still no ideal marker that can replace cystoscopy and urine cytology for the diagnosis of bladder cancer.
Local diagnosis of hematuria lesion
1.According to the relationship between hematuria and the stage of urination, the three-cup urine test can be used to determine more accurately whether the hematuria is initial, final or complete hematuria, so as to infer the location of the lesion.
(1) If it is initial hematuria, it indicates that the lesion is in the urethra and bladder neck. For example, inflammation of the urethra, stones, strictures, tumors, polyps, foreign bodies, prostatitis, prostate enlargement, etc.
(2) If it is terminal hematuria, it is seen in the bladder neck and triangle lesions, such as tumor, inflammation and bladder stone in the bladder neck or triangle.
(3) If the hematuria is complete, it can be seen in lesions of the urinary tract above the bladder, such as non-specific infections, tuberculosis, stones, tumors and lesions of adjacent organs of the urinary system.
2.Inferring the lesion site according to the characteristics of hematuria Fresh hematuria mostly indicates lower urinary tract bleeding, and old hematuria mostly indicates upper urinary tract bleeding; long stripes or earthworm-shaped clots indicate that the bleeding comes from the kidney, and the blood is shaped through the ureter; large amount of hematuria often comes from the kidney or bladder, and the discharge of larger clots mostly comes from the bladder.
The most common symptom of bladder cancer is hematuria without any sensation and visible to the naked eye, which is a unique sign of abnormal urination in bladder cancer and occurs in almost everyone who has bladder cancer.
Compared with hematuria caused by other diseases, hematuria in bladder cancer has two characteristics.
1. First, it is painless. That is, when hematuria occurs, patients have no pain and no other uncomfortable symptoms until cancer necrosis, ulceration and co-infection, then patients will have bladder irritation symptoms such as urinary frequency, urinary urgency and pain. Ta and Tl stage tumors often have no such symptoms. Other symptoms include pain in the lumbar region due to ureteral obstruction, lower limb edema, pelvic mass, and urinary retention. Some patients may present with weight loss, renal insufficiency, abdominal pain or bone pain at the time of consultation, all of which are advanced symptoms.
2. Second, intermittent. That is, hematuria appears intermittently and can stop or reduce on its own. The two episodes of hematuria can be separated by several days or months, or even half a year. This feature can easily make patients have the illusion that hematuria has improved on its own, thus missing out on timely diagnosis and treatment.
“Whenever hematuria occurs, regardless of whether the amount is large or small, even if it is not painful and only occurs once in a long time, it is important to be on high alert and go to a major hospital specialist for an early examination. Because according to clinical data, it is found that 10% to 20% of painless hematuria is related to malignant tumors. If you ignore it, you will miss the disease, miss the best time for treatment and endanger your life.” Whether bladder cancer can be diagnosed early or not is crucial to the patient’s prognosis. For early detection and diagnosis of bladder cancer, we should follow four recipes step by step, namely: abnormal urination should be alert, initial screening of tumor by urinalysis, confirmation of diagnosis by cystoscopy, and comprehensive evaluation by imaging.
1. Abnormal urination should be alerted: painless hematuria.
2.Tumor primary screening urinalysis: urine exfoliation cytology examination.
3.Confirmation of diagnosis through cystoscopy: cystoscopy is the only means to confirm the diagnosis of bladder cancer before surgery.
4.Complete evaluation depends on imaging: intravenous urography and CT examination can help to exclude whether there are suspicious tumors in other urinary system and assess the infiltration scope and depth of bladder cancer and whether there are invasion of surrounding lymph nodes and so on.