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Urologist Fara Bellows discusses her article “When recurrent UTIs might actually be bladder cancer.” Fara shares the story of a 91-year-old patient whose recurrent urinary infections masked an underlying bladder cancer diagnosis, illustrating how easily symptoms can be misattributed. She explains risk factors such as smoking, prior radiation, and occupational exposures, and highlights the alarming statistics that nearly 20,000 women will be diagnosed with bladder cancer in 2025, with close to 5,000 deaths. Fara emphasizes the dangers of delayed diagnosis in women due to symptom overlap with common conditions, and she outlines the three key diagnostic tools—urine cytology, imaging, and cystoscopy—that can save lives when used early. Listeners will learn why vigilance in primary care, proactive referrals, and patient advocacy are crucial to ensuring timely and accurate diagnoses.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Fara Bellows. She is a urologist, and today’s KevinMD article is “When recurrent UTIs might actually be bladder cancer.” Fara, welcome to the show.

Fara Bellows: Thank you so much for having me today, Kevin. I really appreciate it.

Kevin Pho: All right, so let us briefly share your story and then we will jump right into the article that you wrote for us today.

Fara Bellows: Great. So I am a general urologist. I am just past my ten-year work anniversary as an attending urologist. I practiced in Columbus, Ohio for many years, and now I am practicing back on the East Coast where I am from.

Kevin Pho: All right, excellent. And you start your KevinMD article with a case. So tell us about that case and what did it lead to?

Fara Bellows: Yeah, so the case of this lovely woman is an unfortunate situation that I have seen before, and I really wanted to make sure that the public, and especially our medical community, is aware of this as a potential situation. So this lovely woman, who had had pelvic radiation before and had risk factors for bladder cancer, had been treated for urinary tract infections for years by her primary care doctor. She had never seen a urologist before. When I sat down with her, heard her story, and looked at her imaging, I knew exactly what it was. I knew this was bladder cancer and that this had been going on for years, most likely. In fact, the pathology is a very aggressive pathology. I did eventually biopsy her, and it is a cautionary tale for primary care providers, for general practitioners, for other urologists, and anyone who is seeing patients who may report urinary symptoms to keep this diagnosis in the back of their mind.

Kevin Pho: So when you said that you reviewed this case and you knew almost immediately it was bladder cancer, what about that case led you to that conclusion?

Fara Bellows: That is a great question. The most important thing for this woman was that she had been experiencing visible blood in her urine recurrently and ongoing for many years, despite multiple courses of antibiotics. It is a misconception that this is a UTI, which is a very common diagnosis, but we cannot forget about our differential diagnosis, which also includes bladder cancer, bladder stones, kidney stones, and overactive bladder. The list goes on and on. Unfortunately, in this situation, it turned out to be bladder cancer, but this is a life-threatening situation, and so it is important to pass that on to other doctors.

Kevin Pho: So, as you know, I am a primary care doctor and in that primary care setting, we know that visible blood in the urine can sometimes be explained by a UTI, especially in the younger population if it just happens once. You mentioned some words that would make you suspect more, like recurrent episodes or if the hematuria, the visible blood, does not go away. So how can we discern whether that blood is due to a UTI or whether we need to investigate further and refer to a urologist like yourself for bladder cancer?

Fara Bellows: Right. That is a really good question. So getting cultures on file is one important step because visible blood in the urine with a negative urine culture is a really big red flag. If you do not find bacteria in the urine and someone has blood in their urine, they need to see a urologist right away. Another thing to keep in mind is the persistency. This woman had been seeing her primary care provider for three years. I would argue that she would have benefited from an earlier evaluation by a urologist. And another thing to keep in mind is the history. So this woman, she was older, already well into her nineties, and she had pelvic radiation before. The risk factors, smoking history, chemical exposure, and chemotherapy exposure are the things that you want to keep in the back of your mind when you are seeing your patients for blood in their urine.

Kevin Pho: And can you make the distinction between gross hematuria, the visible blood, versus microscopic hematuria and the concerns and approach that we should have for each?

Fara Bellows: Absolutely. So the biggest thing to keep in mind is that while microscopic hematuria, which is just blood on a dipstick or blood on a microscopic urinalysis, does also warrant a workup by a urologist, there is a much higher likelihood of malignancy when it is gross hematuria. If there is visible blood in the urine, it is about a 25 percent chance of finding a pathology versus a 2 percent chance with microscopic hematuria.

Kevin Pho: So when you talk about bladder cancer, specifically in women, it tends to be overlooked as compared to bladder cancer in men. Why is that?

Fara Bellows: A lot of really important reasons for that. Number one, women tend to have situations where they might see more blood down there. We have menstruation, we have postmenopausal bleeding. We tend to have more urinary symptoms in general, such as overactive bladder, frequency, urgency, and burning with urination. So a lot of the symptoms of bladder cancer can be overlooked in women by being confused with other pathologies. Whereas in men, they tend to have maybe some BPH, so they have a weaker stream or they may have to push to urinate, but they do not have the same overactive bladder or dysuria symptoms that women can tend to get. And they certainly do not bleed throughout their lifespan like women do.

Kevin Pho: Are there any studies that we can order in a primary care setting before sending these suspected cases off to a urologist?

Fara Bellows: Absolutely. So one very simple way to check for concern for malignancy is a urine cytology. You send a urine off to the pathologist, they look under the microscope, and they can tell us if there are any abnormal cells that they see. A CT urogram, which is a CAT scan of the abdomen and pelvis with and without contrast, is the gold standard for anyone who sees blood in their urine. For younger patients, you may want to consider a simple ultrasound of the kidneys and bladder, but that CT urogram, as long as their renal function is acceptable and they are not allergic to IV contrast, is the gold standard for blood in the urine.

Kevin Pho: And when we send patients to you, just tell us your workflow, your diagnostic approach when you first see these patients that we refer to you.

Fara Bellows: Sure. So, we have the patients come in. Pretty much everyone provides a urine sample. We check it here in the office. If they have urinary issues like frequency, urgency, or they feel like they are not emptying well, we will do a simple bladder scan to check a residual. We get a full history and do an exam. For men, I certainly make sure that there is a PSA on file if they are of appropriate screening age. And then it is a very simple set of tests. For microscopic hematuria, as long as they are under the age of 60, I will order a renal bladder ultrasound and bring them back for a cystoscopy. If they are over 60 and they meet the criteria, I will get a CT urogram and bring them back for a cystoscopy.

Kevin Pho: And tell us more about a cystoscopy, because when I was in medical school and residency I was taught that was the gold standard in terms of evaluating for hematuria. So tell us where the cystoscopy is in that diagnostic approach.

Fara Bellows: So we do the cystoscopies here in the office, and I have a very low threshold to perform a cystoscopy because our scopes have evolved to become very small, very flexible, and very simple to do in the office. Everyone gets a Uro-Jet, which is a lidocaine jelly, in their urethra, and they get prepped in a sterile fashion, and we do it right here in the office while they are awake. So it is almost like part of our physical exam now as urologists to perform an office cystoscopy to rule out any bladder pathology or any urethral pathology. And I will usually do a GU exam at that time as well.

Kevin Pho: So if you see a suspicious lesion in the bladder from a cystoscopy or the other tests that we talked about, what is the next step?

Fara Bellows: So if we do not already have a cytology on file, I do like to have that because a positive cytology is a worse prognostic sign than a negative cytology. That being said, you can have a negative cytology and bladder cancer, maybe if it is a low-grade tumor. But if I see something that I think is concerning, I will either do an office biopsy if it is very small, or I will bring them to the operating room to resect that tissue and send it off to the lab for a pathologic diagnosis. It is a procedure called a transurethral resection of a bladder tumor, and there are no incisions required. We use a scope that goes into the bladder through the urethra, and we basically scrape that tissue out, send it off to the lab, and we make a tissue diagnosis.

Kevin Pho: And in general, what are some of the outcomes for a diagnosis of bladder cancer?

Fara Bellows: That is a great question. So there is a large paradigm shift between a non-muscle-invasive bladder tumor and a muscle-invasive bladder tumor. Non-muscle-invasive bladder tumors tend to be a little less aggressive and less concerning. They do not generally require aggressive or significantly invasive treatment, whereas muscle-invasive bladder cancer has a far worse prognosis. We tend to treat that with things such as chemoradiation, or even a complete removal of the bladder.

Kevin Pho: You mentioned earlier some risk factors like prior radiation to that area, age, and smoking, but you also mentioned in your article things like workplace exposures and herbal supplements. So talk about how those are underappreciated risk factors.

Fara Bellows: Right. So those are more of the zebras. It depends on the population you work in, but there are aniline dyes in particular, and pesticides, which can be workplace exposures for patients and can put them at risk for bladder cancer. And then there is a traditional Chinese supplement called aristolochic acid, which can also put you at risk for bladder cancer. So those are less commonly seen than things like smoking, but they are certainly still within the risk factor list.

Kevin Pho: And just to reiterate, in the primary care setting, what kind of questions should I be asking that would make me suspect that the hematuria is not run-of-the-mill hematuria that is due to a UTI? What are some red flags that I really need to look out for that would make me send patients to a urologist like yourself?

Fara Bellows: That is a great question. So I think the most important thing to consider is that this tends to be painless hematuria, meaning that the patients have no other symptoms besides literally seeing blood in their urine. And they might see clots too. With UTIs, they may experience burning or pain in their pelvis or in their lower back. This is painless hematuria. That is the red flag.

Kevin Pho: And then from a patient standpoint, if families are listening, are there any practical steps that they can take if they are worried that their UTIs may be something more serious?

Fara Bellows: My best advice is to simply schedule an evaluation with a urologist. It is very easy to rule out bladder cancer. The scope takes about forty-five minutes total. The actual procedure itself only takes about sixty seconds to look around the bladder if you are well versed in how the bladder is expected to look and you have done a lot of cystoscopies, like someone like myself. Schedule an evaluation with a urologist. It is a very low-risk, low-maintenance intervention for a potentially high reward.

Kevin Pho: All right, so taking a step back, just what do we have to look forward to in terms of the diagnosis and treatments of bladder cancer going forward in the foreseeable future?

Fara Bellows: That is a great question. So, bladder cancer in particular has exploded recently with the development of more preventive methods to keep recurrence rates low. In particular for non-muscle-invasive bladder cancer, there is up to a 70 percent recurrence rate, so the surveillance schedule after bladder tumor removal is very intense. Now if you do have a recurrence when you have non-muscle-invasive bladder cancer, it is recommended to have what we call intravesical therapies. The gold standard there has been BCG (attenuated live tuberculosis vaccine) for decades, but that field has exploded recently in terms of the upcoming intravesical therapies.

Another big paradigm shift that we have seen is more bladder-sparing therapy for muscle-invasive bladder cancer. So chemoradiation is being employed more, especially for older, sicker patients who might not tolerate a big operation like a radical cystectomy. We have basically expanded the treatment options for patients with bladder cancer in the last ten years. It is almost hard to keep up with how many therapies are coming on the market, and there is always new literature talking about some new agent.

Kevin Pho: We are talking to Fara Bellows. She is a urologist, and today’s KevinMD article is “When recurrent UTIs might actually be bladder cancer.” Fara, let us end with some take-home messages that you want to leave with the KevinMD audience.

Fara Bellows: Yeah, so I think the most important thing to consider is, I know everyone takes really good care of their patients, but just do not forget those little things, those little possibilities in terms of possible diagnoses. If a woman is seeing blood in her urine, she certainly warrants a further evaluation. We know that women tend to be diagnosed with bladder cancer at more aggressive stages and later, and they have higher mortality rates. It may be because it is simply overlooked or thought of as a different type of pathology, but just having a really low threshold to have your patients see a urologist and get evaluated properly, I think is really important.

Kevin Pho: Fara, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Fara Bellows: Thanks so much for having me. I really appreciate it.