A 57-year-old man has a routine urinalysis as part of his company's yearly required physical examination. He has a chronic cough (50 pack/year smoking history). His only complaints referable to the urinary tract are some mild dysuria and hesitancy, but he otherwise feels fine. On physical examination there are no abnormal findings.

Questions:

1. What do these findings suggest?

The atypical urothelial cells suggest the possibility of a carcinoma. The presence of the RBC's is consistent with that.

2. What further studies are indicated?

He should be referred to a urologist, who can do cystoscopy to look at the bladder urothelium, collect urine for cytology, and biopsy any suspicious areas. For lesions that could be higher (ureter, renal pelvis), an IVP and CT scan can be of use.

3. What social or environmental history would be important?

Smokers have an increased risk for urothelial malignancies. A history of exposure to beta-naphthylamine and analine dyes is also a risk. Persons with chronic Schistosoma hematobium infection (Egypt is one endemic area) may develop squamous cell cancers of the bladder.