As a urologist, I see recurrent UTI patients nearly every day, and most cases are routine: nasty bacterial infections that appear in the bladder every few months. However, a recent patient turned out to be the zebra rather than the horse. This particularly lovely woman was 91, an Italian immigrant, and was accompanied by her adult son, who helped provide history and translate as needed. She sat calmly on the exam table, her hands resting in her lap, her nails a pristinely manicured siren red. She smiled serenely at me as her son gave her history. “She had her uterus taken out for cancer, and got radiation for it, but she’s been urinating blood for the last 3 years. She keeps getting these bladder infections. They give her antibiotics and it gets better, but this time, it’s not going away. She’s peeing blood and it burns her when she goes to the bathroom.”

My ears prick up at the mention of pelvic radiation. As I scrolled through her CAT scan, I asked gently, “Who are ‘they?'” He waved his hand and responded, “Oh, you know, her primary doctor. He’s been taking care of these infections for the last few years but we thought it was time she saw a specialist.” Between considering her cancer history and the CAT scan materializing in front of me, I note a haziness on the right upper corner of her bladder. These aren’t UTIs, I think to myself. This is bladder cancer.

According to the American Cancer Society, in the year 2025, nearly 20,000 women will be diagnosed with bladder cancer, and nearly 5,000 women will die of it. Risk factors for development of bladder cancer include smoking, workplace exposures (such as aniline dyes), exposure to certain herbal supplements, pelvic radiation, history of receiving cyclophosphamide, and family history of bladder cancer. Presenting symptoms typically include gross hematuria, but may also include urine storage symptoms such as urinary frequency or urgency, or burning with urination. These symptoms can easily be confused with UTIs, especially in women.

There is literature to suggest that women are at higher risk for more aggressive bladder cancer, which may be due to delayed diagnosis. In fact, women appear to be less likely than men to receive a full workup for blood in the urine, or to even receive a referral for urology in the first place. The danger of delayed diagnosis of bladder cancer cannot be understated. In fact, it has been shown that such a delay increases risk of death from bladder cancer.

One may surmise that because of various female-specific conditions such as menstruation, post-menopausal vaginal bleeding, and higher susceptibility to UTIs, women may downplay their symptoms or fail to advocate for themselves to see a specialist. However, for many women who primarily see their primary care physicians or gynecologists for medical care, their symptoms may also be misconstrued as those of typical recurrent UTIs or overactive bladder.

There are a number of possible means we can employ when considering early and timely diagnosis of bladder cancer. Primarily, those in primary care and women’s health must remain vigilant of the possibility of a bladder cancer diagnosis in women, especially for those with visible blood in the urine. Even if culture-proven UTIs are present, these two diagnoses can overlap and a urologic evaluation should be strongly considered.

Furthermore, any patient with risk factors for bladder cancer and visible blood in the urine should probably see a urologist, especially if urine cultures are negative. Only three diagnostic studies are required for anyone who sees blood in the urine: a urine cytology to rule out cancer cells, some form of upper tract imaging (usually renal ultrasound or contrast-enhanced CT scan), and a diagnostic cystoscopy, an office-based test to look inside the bladder to rule out visible tumor. These tests are safe, effective, and low risk, and aside from the cystoscopy, can be ordered by primary care.

Finally, we must remember that bladder cancer can easily mimic a number of more common urologic conditions such as recurrent UTIs and overactive bladder. If there is an index of suspicion, do not hesitate to investigate further. Even a basic renal bladder ultrasound can rule out any gross anatomic abnormalities.

It is essential that we continue to advocate for these women and ensure that they receive the medical care and attention they deserve. The next time you see a woman who is urinating blood, I implore you to think twice before simply treating her with Cipro and sending her on her way until the next time it happens. You could potentially save her life.

Fara Bellows is a urologist.