Painless Gross Hematuria Leads to Early Diagnosis of Low-Grade Non-Invasive Urothelial Carcinoma in 64-Year-Old Male
Discovering cancer early can make all the difference—this is especially true when it comes to bladder cancer, where symptoms like painless blood in the urine often go unnoticed or are mistaken for less serious conditions. In this case, a 64-year-old man experienced recurring gross hematuria over six months before receiving an accurate diagnosis of low-grade non-invasive urothelial carcinoma. Thanks to timely imaging, cystoscopy, and surgical intervention, the tumor was successfully removed, and with ongoing preventive therapy, no recurrence has been detected. This story highlights the importance of vigilance, proper diagnostic follow-up, and patient education in managing early-stage bladder cancer.
Understanding the Patient's Journey: From Symptoms to Diagnosis
Initial Presentation and Misdiagnosis
A 64-year-old male presented at our outpatient clinic accompanied by family members due to persistent painless gross hematuria that had occurred intermittently over the past six months. The discoloration affected his entire stream of urine—bright red without clots—and he reported no urgency, frequency, or discomfort during urination. Initially, local healthcare providers diagnosed him with a urinary tract infection (UTI) and administered intravenous antibiotics, which temporarily resolved the symptom. However, each time the hematuria returned, it was again attributed to another UTI episode, delaying further investigation.
This cycle continued until the patient sought care at a tertiary medical center. Upon evaluation, urinalysis confirmed significant microscopic hematuria, prompting advanced imaging. A genitourinary ultrasound revealed a suspicious neoplasm near the right ureteral orifice within the bladder. To confirm the finding, a cystoscopic examination was performed, clearly showing a papillary lesion located just above and outside the right ureteral opening.
Clinical Suspicion Confirmed
The visual appearance during cystoscopy raised strong suspicion for malignant transformation. Based on these findings, a preliminary diagnosis of bladder malignancy was made, setting the stage for definitive treatment planning.
Treatment Approach: Surgical Intervention and Adjuvant Therapy
Surgical Management
After discussing the risks, benefits, and alternatives with the patient—who expressed willingness to proceed despite initial anxiety—he was admitted for surgery. Preoperative assessments showed no contraindications, and the following day, he underwent transurethral en bloc resection of the bladder tumor under general anesthesia. This modern technique allows complete removal of the lesion while preserving surrounding tissue integrity, improving pathological assessment accuracy.
Postoperatively, continuous bladder irrigation was initiated to prevent clot formation and potential catheter obstruction. Recovery was smooth, with minimal discomfort reported.
Pathological Confirmation and Risk Stratification
Final histopathology results confirmed the diagnosis: low-grade non-invasive urothelial carcinoma. Importantly, there was no evidence of muscularis propria invasion, classifying the disease as non-muscle-invasive bladder cancer (NMIBC), Ta stage. Given its low-risk profile, the prognosis was favorable, but recurrence prevention remained critical.
Adjuvant Intravesical Chemotherapy
To reduce the likelihood of tumor recurrence, the patient received six cycles of intravesical chemotherapy using mitomycin C. Administered directly into the bladder via a catheter, this localized treatment targets residual abnormal cells while minimizing systemic side effects. The regimen followed international guidelines, including an induction phase immediately post-surgery.
Outcomes and Follow-Up Plan
Positive Clinical Response
Three days after surgery, the patient was discharged in stable condition. He reported improved well-being and absence of hematuria. At the three-month follow-up, both physical examination and imaging studies—including repeat cystoscopy and renal-bladder ultrasound—showed excellent wound healing and no signs of tumor recurrence.
Long-Term Surveillance Strategy
Given the nature of NMIBC, even low-grade tumors carry a risk of recurrence. Therefore, a structured surveillance protocol was established:
- Years 1–2: Cystoscopy and urinary tract ultrasound every 3 months
- Years 3–5: Monitoring every 6 months
- Year 6 onward: Annual evaluations
In addition, annual comprehensive health checkups were recommended to monitor overall wellness and detect any other age-related conditions early.
Key Recommendations for Patients Post-Treatment
Dietary and Lifestyle Modifications
Nutrition plays a vital role in recovery and long-term health. Patients are encouraged to adopt a diet rich in fresh fruits, vegetables, whole grains, and lean proteins. Processed foods such as pickled, smoked, or cured meats should be limited or avoided, as they contain nitrosamines and other carcinogenic compounds linked to increased bladder cancer risk.
Hydration and Urine Monitoring
Staying well-hydrated helps flush out toxins from the urinary system. Drinking plenty of water throughout the day dilutes urine and reduces irritation to the bladder lining. Patients should also routinely observe their urine color and clarity. The sudden return of pink, red, or cola-colored urine warrants immediate medical attention, as it may signal tumor recurrence or other urological issues.
Personal Hygiene Practices
Maintaining genital hygiene is essential to prevent infections that could complicate recovery. Daily cleaning with running water—without harsh soaps or irritants—helps keep the perineal area clean and dry. Good hygiene supports urinary tract health and minimizes inflammation that might mimic or mask disease symptoms.
Why This Case Matters: Raising Awareness About Bladder Cancer
Recognizing the Red Flag: Painless Hematuria
Bladder cancer ranks among the most common urological malignancies worldwide. Its hallmark symptom—painless gross hematuria—is present in up to 85% of cases. Yet, because the bleeding can be intermittent and self-limiting, many patients mistakenly believe the issue has resolved on its own. This false reassurance often leads to delayed diagnosis and missed opportunities for early intervention.
The Importance of Definitive Diagnostic Tools
While urinalysis and ultrasound are valuable screening tools, they are not sufficient for ruling out bladder cancer. When unexplained hematuria occurs—even once—cystoscopy remains the gold standard for direct visualization of the bladder mucosa. It enables early detection of small, flat, or papillary lesions that imaging alone might miss.
Encouraging Proactive Healthcare Seeking
Patients must understand that recurrent blood in the urine is never normal and should never be ignored—even if asymptomatic. Public education campaigns, primary care provider awareness, and access to specialty services are key to improving outcomes in bladder cancer.
For clinicians, this case reinforces the need to look beyond common diagnoses like UTIs when treating older adults with hematuria. A thorough workup, including endoscopic evaluation, can uncover life-altering conditions before they progress.