Editor,—Large numbers of patients are seen in departments of genitourinary medicine with symptoms suggesting infection or inflammation of the genitourinary tract. Although bladder neoplasms typically cause painless haematuria, in a subgroup of patients they cause other urinary symptoms that may produce diagnostic confusion. We identified five patients who were referred to the genitourinary medicine service, and who were found to have bladder carcinoma (see table 1). Four of the patients presented to the genitourinary medicine department at High Wycombe (5500 new attendances per annum) between 1991 and 1998; the fifth patient presented to the Oxford genitourinary medicine department (9000 new attendances per annum) in 1997. None of the patients had an occupational history that placed them at higher risk for bladder cancer.

Men with bladder carcinoma typically present in later life (median age 69 years), but the condition may occur at younger ages.¹ A subgroup of patients develop frequency, urgency, and dysuria—symptoms usually associated with bladder infection.² Rarely, penile and perineal pain mimicking prostatitis may be a presenting feature, as in patients 3 and 4, who have been described in more detail elsewhere.³

Non-specific urethritis (NSU) is diagnosed commonly in genitourinary medicine clinics in men of all ages. In this series, patient 2 was referred with presumed NSU, and patient 4 had attended previously with a diagnosis of NSU, 2 years before the bladder cancer was diagnosed (at that time there were 5–10 white cells/high power field (×1000) on a urethral smear, and a chlamydia ELISA test and cultures for Neisseria gonorrhoeae were negative; no haematuria was detected). Both patients were subsequently noted to have neoplastic infiltration in the bladder neck area and prostatic urethra.

In all five cases a degree of persistent microscopic haematuria was noted at presentation; in patient 4 this was never greater than a trace on dipstick testing. Patient 1 reported intermittent painless macroscopic haematuria at presentation; he was referred by his general practitioner with suspected genitourinary infection, rather than suspected neoplasia, because of his young age (26 years).

Bladder neoplasia is especially liable to cause irritative symptoms when represented by, or associated with, carcinoma in situ of the bladder urothelium.^{1, 2} Urine cytology may be useful in this subgroup, and was abnormal in all three of the five patients in whom it was requested. When this process involves the prostatic urethra, symptoms mimicking prostatitis may arise. Early diagnosis of bladder neoplasia is of prognostic importance; the presence of carcinoma in situ or prostatic involvement by bladder carcinoma are poor prognostic features for which radical surgery may be required.^{1, 4}

These cases highlight the importance of careful follow up of patients presenting with persistent irritative-type bladder symptoms, especially in an older age group, when specific tests for genitourinary infection are negative, and where microscopic haematuria is a feature. Bladder carcinoma should be considered in this subgroup; urine cytology and referral for cystourethroscopy may be indicated. Although rare in younger adult males, bladder cancer should not be ruled out in men under the age of 45 years, and our experience strengthens the case for continuing with routine urine testing in genitourinary medicine clinics.