Urethral Cancer Clinical Presentation

Updated: Oct 13, 2021
  • Author: Shahrokh F Shariat, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Presentation

History

The signs and symptoms of urethral cancer vary and are neither diagnostic nor pathognomonic. Generally, the onset is insidious, and symptoms are usually more attributable to benign stricture disease (ie, bladder outlet obstruction, overflow incontinence) rather than malignancy (ie, perineal pain, hematuria). In fact, in both sexes, cancer may be completely asymptomatic except for a hard nodular area in the perineum, labia, or along the course of the penis.

The interval between the onset of symptoms and diagnosis may be as long as 3 years because of misdiagnoses and failure by the patient to seek medical consultation. Male patients may initially be diagnosed with more common causes of symptomatology such as benign prostatic hyperplasia (BPH) or urinary tract infection. Further investigation should be performed if a suspected urinary tract infection recurs quickly or if symptoms fail to resolve.

Remember also that these tumors have a propensity to be highly advanced locally at the time of diagnosis. A raised index of suspicion is advisable if an elderly man presents with stricture disease, particularly if symptoms are more consistent with malignancy or local extension (ie, urethral fistulae, abscess formation, and necrosis).

Although stricture disease is less common in women, chronic inflammation or irritation in the form of infection, urethral polyps, caruncles, or urethral diverticula can give clues to the presence of urethral carcinoma. [14]

Diminished stream, straining to void, and other obstructive voiding symptoms are common. Although these are often the symptoms of benign stricture disease or BPH, a neoplasm may be concealed by the presentation of a routine stricture. Maintain a high index of suspicion in patients with a history of urethral stricture disease and keep a vigilant eye over the proceeding cytological analysis, radiographic imaging, and cystoscopy.

Frequency, nocturia, itching, dysuria, and other irritative voiding symptoms are reported in association with carcinoma in situ. Incontinence is generally overflow incontinence caused by bladder outlet obstruction due to urethral stricture disease. However, severe urgency may progress to urge incontinence and distortion of the urethral anatomy in females and may lead to stress urinary incontinence.

Other signs and symptoms include:

  • Urinary retention from progressive urethral stricture disease
  • Hematuria, urethral or vaginal spotting
  • Purulent, foul-smelling, or watery discharge
  • Hematospermia
  • Perineal, suprapubic, or urethral pain
  • Dyspareunia
  • Swelling
  • Tenesmus
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Physical Examination

Early evaluation should include a thorough physical examination, including a complete genital and rectal examination, with palpation of the entire urethra and perineum. Care should be taken to palpate along the entire urethra and regional lymph nodes, as local invasion occurs early in the disease. Presence of lymphadenopathy should be noted for later surgical consideration. The meatus should be examined closely with attention to mucosal irregularities or bloody discharge.

Sexually transmitted diseases increase the risk of urethral cancer and should be identified routinely during the examination. The perineum should be examined for abscesses and fistulae, as these may be a sign of locally advanced disease.

Bimanual examination should be performed as well since it allows the clinician to estimate the extent of local invasion and involvement of the bladder.

Physical examination findings include:

  • Urethrocutaneous fistula
  • Urethrovaginal fistula
  • Periurethral abscess or areas of tissue necrosis
  • Recurrent urinary tract infection
  • Penile or vaginal lesions
  • Lymphadenopathy
  • Palpable mass along the course of the urethra
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