Association between symptoms of acute cystitis and findings of bladder cancer in the Swedish standardized pathway for macroscopic haematuria

Standardized Care Pathway (SCP) for patients presenting with macroscopic haematuria was introduced in Sweden in 2015. In contrast to neighbouring countries, the Swedish model includes all patients with macroscopic haematuria above the age of 50, notwithstanding obvious causes. The aim of this study was to characterize the patients referred within the SCP and the presence of acute cystitis. All patients admitted to two regional hospitals in 2023, under the terms of SCP macroscopic haematuria, were included. Patient data were collected retrospectively regarding age, sex, symptoms of cystitis and cause of haematuria. The study included 782 patients. The median age was 70 years and half were women. In 89 cases, a urinary tract cancer was found (11%) and 74 (9%) had bladder cancer. The cancer-positive group was significantly older (median 75 years) and 76% were men. Half of patients (51%) had symptoms of acute cystitis on referral. This was significantly associated with the absence of bladder cancer, but only in the age groups 50-69, where no case was found among patients with symptoms of cystitis. In the age groups above, 22 cancer-positive patients (30% of all bladder cancer cases) had symptoms of cystitis. The Swedish SCP macroscopic haematuria targets younger female patients unproportionally, in comparison to where cancer is likely found. Neither symptoms of cystitis, nor positive urine cultures exclude bladder cancer in elderly, but clearly in the age groups 50-69. If excluding the latter from the SCP, a 28% reduction of examined patients can be achieved with a negligible risk of missing cancer.