Painless visible haematuria as the presentation of bladder cancer

The usual type of bladder cancer is transitional cell carcinoma, also known as urothelial carcinoma. It grows from the urothelium, the specialised lining of the urinary tract.

The commonest way it shows itself is painless visible haematuria. Visible (macroscopic) haematuria is blood you can see, whereas microscopic (invisible) haematuria is picked up on a urinary dipstick. The tumour's surface bleeds into the urine, and early on it usually does not block urine flow or inflame the bladder, so pain is often absent. That is why the symptom can be dismissed or delayed.

Other features can occur but are non-specific. Lower urinary tract symptoms, which include nocturia (passing urine at night), urgency and frequency, are shared with many benign conditions and with infection, so they do not separate cancer from them. Pelvic pain suggests locally advanced disease (the tumour has grown through the whole bladder wall into the surrounding structures), and symptoms of metastases (spread to distant organs) belong to late-stage disease.

Visible haematuria can come and go, so one clear sample does not rule cancer out. A person aged 45 or over with unexplained visible haematuria and no urinary tract infection, or with visible haematuria that persists or recurs after successful treatment of a urinary tract infection, meets the NICE suspected-cancer criteria and should receive an urgent referral. The main test is cystoscopy, in which a thin camera is passed through the urethra to look at the bladder lining.

Smoking is the greatest risk factor, and the typical patient is a man aged 50 to 80 years. Bladder cancer is more common in men and in smokers, but a woman with painless visible haematuria still needs investigation.