Cases corner – 66yr old female with vaginal discharge and haematuria

19th February 2020

Sofia, a 66yr old female, presents to you with a 4 week history of vaginal discharge. The discharge is clear in colour, non-odorous, and does not cause her any discomfort. She denies any abdominal pain or vaginal bleeding. Sofia was seen by one of your colleagues a couple of weeks ago and a high vaginal swab and STI screen was taken. The results of these tests were normal. You also note that your colleague has documented a normal speculum and bi-manual examination

She has come back into your surgery today for the results of her swab. She also mentions to you that she has seen some blood in her urine over the last couple of days. Sofia denies any dysuria, suprapubic pain, or increase in frequency. She has no systemic symptoms such as fever, weight loss or appetite loss.

The patient has a history of depression and has been taking Citalopram 20mg for the last 18 months. On examination her observations are all normal and her abdomen is soft and non-tender. A urine sample finds blood +++, but no leukocytes or nitrites.

What would you do next?

  1. Prescribe antibiotics and give safety-netting advice
  2. Send an MSU and review with the results
  3. Consider an abdominal/pelvic USS
  4. Consider an abdominal/pelvic CT scan
  5. Refer the patient via the urology 2-week-wait pathway

Sofia has presented with unexplained vaginal discharge and visible haematuria. This raises the suspicion of both urological cancer and endometrial cancer. To start with, she has new visible haematuria without any obvious signs of infection, and in this case NICE cancer guidelines advise the following:

  • Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) fir bladder cancer if they are:
    • Aged 45 and over and have:
      • Unexplained visible haematuria without urinary tract infection
      • Visible haematuria that persists or recurs after successful treatment of urinary tract infection
    • Aged 60 and over and have unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test. [new 2015]
  • Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for renal cancer if they are 45 and over and have:
    • Unexplained visible haematuria without urinary tract infection
    • Visible haematuria that persists or recurs after successful treatment of urinary tract infection. [new 2015]

However, Sofia is also experiencing unexplained vaginal discharge. The ENDOMETRIAL guidelines from NICE also advise the following:

  • Consider a direct access ultrasound scan to assess for endometrial cancer in women aged 55 and over with:
    • Unexplained symptoms of vaginal discharge who:
      • Are presenting with these symptoms for the first time
      • Have thrombocytosis
      • Report haematuria
    • Visible haematuria and:
      • Low haemoglobin levels
      • Thrombocytosis
      • High blood glucose levels [new 2015]

This case illustrates how the symptoms of different tumour sites can overlap, especially in early cancer, and the importance of considering simultaneous investigations in order to get a diagnosis as quickly as possible.