In this case, we should suspect bladder carcinoma ( transitional cell carcinoma ) . Smokers are at a higher risk of developing TCC.Other risk factors being chemical .industry workers in western countries and schistosomiasis in endemic regions . It is more common in males -3:1. They usually presents with painless gross hematuria. Thus the best option here is urine microsopy for RBC's and malignant cells.urine cytology even though not a good screening test because of lack of sensitivity is highly specific . Mainstay of diagnosis is cystourethroscopy. investigations include imaging ( CT , MRI ,USG ,IVU ) and blood investigations for HB , electrolytes and urea . Bailey and Love 27th edition.chapter 77.pg no 1449.