Urethral cancer differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [5]; Associate Editor(s)-in-Chief: Mehrian Jafarizade, M.D [6], Vindhya BellamKonda, M.B.B.S [7]

Overview

Urethral cancer must be differentiated from bladder cancer, cervical cancer, bladder stones, ureteral stones, cystitis, neurogenic bladder, and urethritis.

Differentiation

Urethral cancer must be differentiated from other diseases that cause lower urinary tract irritation symptoms (e.g., dysuria, urgency and frequency in addition to urethral discharge); these include Bladder cancer, Cervical cancer, urethritis, Bladder stones, cystitis, urethrolithiasis, Neurogenic bladder, cervicitis, vulvovaginitis, and epididymitis.

• The following table summarizes the differential diagnosis for Urethral cancer:

Diseases	Symptoms							Physical Examination				Diagnostic tests			Past medical history
	Hematuria	Pyuria	Frequency	Urgency	Dysuria	Weak urine stream	Mass	Fever	Tenderness	Discharge	Inguinal Lymphadenopathy	Urinalysis	Urine Culture	Gold Standard
Urethral Cancer	+	–	+/–	+/–	+/–	+	+	–	–	–	–	Malignant cells RBC	–	Biopsy	Personal history of bladder cancer. Conditions that cause chronic inflammation in the urethra, including: Sexually transmitted diseases (STDs), including human papillomavirus (especially HPV type 16) Frequent urinary tract infections (UTIs) White female Age 60
Bladder cancer	+	–	+/–	+/–	–	–	+/–	–	–	–	–	Malignant cells RBC	–	Biopsy	Smoking Occupational exposure to chemicals: Textiles, Rubber, Paint, Leather, Dye, Metal, Machining, Plastics, Arsenic, Aristolochic acids Chronic bladder irritation Chronic urinary tract infection Bladder stones Schistosoma haematobium Trauma Chemotherapy: yclophosphamide, Ifosfamide Radiation therapy Personal history of cancer in the urinary tract Congenital bladder anomalies such as rachus, Exstrophy
Cervical cancer	–	–	+/–	+/–	–	–	+/–	–	–	–	–	–	–	Biopsy	Specific risk factor: Human papillomavirus (HPV) infection: Other risk factors for cervical cancer include the following: Smoking HIV infection Increased number of sexual partners Young age at time of first sexual intercourse Hormonal contraception High parity DES (diethylstilbestrol):
Bladder stones	+	–	+	+/–	+/–	–	–	–	–	–	–	RBC	–	CT scan without contrast	Common risk factors in the development of nephrolithiasis include: Dietary habits Low urinary pH Hypercalcemia Hypercalciuria Hyperoxaluria Hyperuricemia Hyperuricosuria Metabolic syndrome Obesity Diabetes mellitus Environmental - such as hot climate Drugs Thiazide Furosemide Sulfadiazine Indinavir
Ureterolithiasis	+	–	+	+	+/–	–	–	–	–	–	–	RBC	–	CT scan without contrast	Same as bladder cancer
Neurogenic bladder	–	–	+/–	+/–	–	–	–	–	–	–	–	–	–	Urodynamic study (UDS)	Spinal cord diseases, injuries Neural tube defects including spina bifida. Brain tumors
Urethritis	–	+	–	–	+	+/–	–	+	–	Urethral discharge	+	Positive leukocyte esterase test or >10 WBCs Mucous threads in the morning urine	–	Gram stain & mucoid or purulent discharge	Prior STDs Urinary tract infections New sexual partner Recent intercourse Recent catheterization
Cystitis	+	+	+	+	+	–	–	+	Suprapubic	–	+	Nitrite +ve Leukocyte esterase +ve WBCs RBCs	>100,000CFU/mL	Urine culture	Recent catheterisation Pregnancy Recent intercourse Diabetes Personal or family history of UTI Known abnormality of the urinary tract BPH HIV
Diseases	Symptoms							Physical Examination				Diagnostic tests			Past medical history
	Hematuria	Pyuria	Frequency	Urgency	Dysuria	Weak urine stream	Mass	Fever	Tenderness	Discharge	Inguinal Lymphadenopathy	Urinalysis	Urine Culture	Gold Standard
Vulvovagintis	–	–	–	–	+			+	–	Vaginal discharge	+	–	–	Gram stain & culture of discharge	Number and type of sexual partners (new, casual, or regular) Prior STDs Previous history of symptomatic BV in female partner (in homosexual women)
Cervicitis	–	+	–	–	+			+	Cervical	Endocervical exudate	–	–	–	Culture for gonococcal cervicitis	Abnormal vaginal bleeding after intercourse or after menopause Abnormal vaginal discharge Painful sexual intercourse Pressure or heaviness in the pelvis
Epididymitis	+	–	+	+	+			+	Testicular & suprapubic	+/– urethral discharge	+	Hematuria may be seen	+	Culture	Unilateral, gradual, and localized scrotal pain posterior to the testis Scrotal swelling Scrotal wall erythema Constitutional symptoms: feeling warm, chills, nausea and vomiting