Symptoms of Bladder Cancer
Primary Presenting Symptom
Painless hematuria is the hallmark presenting symptom of bladder cancer, occurring in more than 80% of patients, and any episode—whether gross or microscopic, intermittent or resolved—mandates urgent urologic evaluation. 1
Hematuria Characteristics
Gross (visible) hematuria occurs in 70-80% of bladder cancer patients and is typically painless and intermittent. 1
Microscopic hematuria may be the sole manifestation and warrants the same diagnostic urgency as gross hematuria. 2
The absence of pain increases the likelihood of underlying malignancy compared to painful hematuria. 3
Intermittent or self-limited hematuria should never be dismissed—even a single episode requires complete urologic work-up. 2, 3
Irritative Voiding Symptoms
Dysuria, urinary frequency, and urgency are common presenting symptoms, particularly in patients with invasive or high-grade tumors. 1, 2, 4
These irritative lower urinary tract symptoms frequently mimic urinary tract infection, leading to diagnostic delays. 2, 4
Patients may initially present with what appears to be recurrent urinary tract infection. 2
Even mild lower urinary tract symptoms warrant consideration for malignancy evaluation, as they may represent underlying bladder cancer. 4
Symptoms of Advanced Disease
Flank pain, bone pain, or suprapubic pain indicate potential advanced disease requiring urgent metastatic work-up. 2, 4
Flank pain suggests ureteral obstruction or retroperitoneal metastases. 2, 4
Upper tract obstruction is a red-flag sign of advanced disease. 2
Distant metastases are uncommon at initial presentation but must be evaluated when pain symptoms are present. 2
Patient Demographics and Risk Factors
Approximately 70% of bladder cancer patients are older than 65 years at diagnosis, with a median age of 73 years. 1, 2
Male sex carries markedly higher incidence (approximately 17.7 per 100,000) compared to females (approximately 3.5 per 100,000). 1, 2
Tobacco smoking is the most important modifiable risk factor for bladder cancer development. 2, 3
Critical Clinical Pitfalls to Avoid
Never attribute hematuria solely to anticoagulation therapy—full urologic work-up is mandatory regardless of medication use. 2, 3
Never assume painless hematuria is benign—it is more strongly associated with malignancy than painful hematuria. 2, 3
Never dismiss resolved or intermittent hematuria—any single episode warrants comprehensive evaluation including cystoscopy and upper tract imaging. 2, 3
Never overlook irritative voiding symptoms as simple infection—they may represent high-grade or invasive malignancy. 2, 4
Immediate Actions Required
Any episode of gross hematuria mandates complete urologic evaluation with office cystoscopy and upper tract imaging, irrespective of patient age or comorbidities. 2, 3
Patients presenting with pain symptoms (flank or bone pain) require urgent CT imaging of chest, abdomen, and pelvis to assess for metastatic disease. 2, 3
Urine cytology should be obtained at the time of or before cystoscopy to detect high-grade urothelial carcinoma. 3