Diagnosis and Treatment of a Rare Bladder Urothelial Papilloma in a 9-Year-Old Boy: A Case Report

Diagnosis and Treatment of a Rare Bladder Urothelial Papilloma in a 9-Year-Old Boy: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Diagnosis and Treatment of a Rare Bladder Urothelial Papilloma in a 9-Year-Old Boy: A Case Report Guotao Liao, Zhiguo Zhang, Weiwei Cao, Meng Zuo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7067543/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Bladder tumors are relatively rare in pediatric populations. Given the limited understanding and documentation of such cases, we present this report to describe the diagnosis and management of a rare case of bladder urothelial papilloma (UP) in a 9-year-old male patient. The patient was admitted for evaluation of hematuria discovered by his family. A comprehensive history revealed no known risk factors except for a habit of chewing on a water-based pen nib, which may represent a potential exposure route to chemical dyes. Detailed diagnostic workup confirmed the presence of a bladder mass, leading to transurethral laser resection (TURL) as the treatment modality. Histopathological examination identified UP, and follow-up at 3 and 6 months postoperatively showed no recurrence. This case highlights critical factors in diagnosing and managing pediatric bladder tumors, with special attention to how children's daily habits may impact the condition. Bladder tumor Urothelial papilloma Pediatric urology Case report Risk factors Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Bladder cancer is a common malignant tumor in urology and ranks as the second most frequent urinary system malignancy after prostate cancer. Globally, it is the seventh most diagnosed cancer in men (second only to prostate cancer) and the 13th leading cause of cancer-related mortality 1 . Its pathogenesis likely involves a complex interplay of physicochemical and biological factors. In China, established risk factors for bladder cancer, as outlined in urological guidelines, include smoking, occupational chemical exposures, chronic urinary tract infections, long-term consumption of arsenic-contaminated water, and *Schistosoma* infection 2–3 . Alterations in genes such as *HER-2*, *HARS*, and *Bcl-2* in bladder urothelial tissue may contribute to tumorigenesis through diverse mechanisms. Although the molecular pathways underlying bladder cancer development remain incompletely understood, it is widely accepted that any factor promoting uncontrolled proliferation of urothelial cells along with nuclear abnormalities may play a role in disease initiation and progression. Pediatric bladder tumors are exceptionally rare, and due to their young age and limited environmental exposures, children typically lack conventional risk factors such as smoking or prolonged occupational chemical exposure. Consequently, research on the etiology and risk factors of pediatric bladder tumors remains scarce, with limited clinical evidence available. In this case, the child exhibited a habit of chewing on a water-based pen nib, raising the possibility of novel environmental or behavioral risk factors contributing to bladder tumor development in pediatric patients. Case presentation The patient was a 9-year-old male child who presented for medical care in August 2024. He did not exhibit symptoms such as urinary frequency, dysuria, or lower abdominal discomfort. Blood-tinged urine was also not self-reported by the child; however, he was brought to the clinic because blood-stained underwear was detected by his family members. Initially, the possibility of hematuria was not confirmed by the family upon presentation. upon review of the patient's medical history, no family history of bladder cancer was identified. Potential risk factors including exposure to tobacco smoke, residence in schistosomiasis-endemic regions, hair dye use, and genetic predisposition were all excluded. Notably, the patient reported a chronic habit of chewing on a water-based pen nib. The patient initially presented to an external hospital where renal function tests showed normal results. A contrast-enhanced computed tomography (CT) scan of the urinary system (Figs. 1 – 2 ) revealed an enhancing mass adjacent to the posterior bladder trigone. Based on these clinical and radiographic findings, bladder malignancy was strongly suspected. Subsequently, the patient was referred to our hospital's urology department for further management. Upon admission, we prioritized this case and performed a comprehensive color Doppler ultrasound examination of the urinary system (Figs. 3 – 4 ). The ultrasound demonstrated a small lesion on the posterior bladder wall with detectable vascular signals, further supporting the diagnosis of bladder tumor. After completing preoperative laboratory investigations, the patient underwent holmium:YAG laser enucleation on hospital day 3. Intraoperative findings revealed a cauliflower-like exophytic lesion measuring 1.2 × 1.0 cm located at the junction of the right trigone, posterior wall, and right lateral wall (Fig. 5 ). Microscopic examination demonstrated a pedunculated tumor with multiple implantation bases, featuring elongated spindle-shaped nuclei with distal enlargement, accompanied by prominent vascular proliferation within and surrounding the tumor. To minimize the risk of iatrogenic injury to the intramural right ureter and subsequent ureteral stricture, a 4Fr ureteral catheter was placed intraoperatively to provide support and guidance during laser ablation. The tumor was completely excised using a holmium:YAG laser (37.5W output power) with dissection extending to the muscularis propria layer. The surgical specimen and intraoperative documentation were reviewed by the family members prior to submission for histopathological analysis. Postoperative management included adjuvant intravesical epirubicin chemotherapy. Both ureteral and Foley catheters were successfully removed on postoperative day 7, with no subsequent reports of voiding dysfunction or flank pain. Histopathological examination confirmed the final diagnosis of UP with mild-to-moderate atypical hyperplasia (Fig. 6). Given the complete surgical excision and favorable pathological findings, adjuvant intravesical chemotherapy was deemed unnecessary. The patient underwent regular follow-up at 3 and 6 months postoperatively, with surveillance bladder ultrasounds showing no evidence of tumor recurrence. Clinical evaluation revealed absence of hematuria, dysuria, or urethral discharge, and renal ultrasonography demonstrated no hydronephrosis bilaterally. The patient maintained an uneventful recovery throughout the follow-up period. Discussion Although the incidence of bladder tumors is high in the general population, these tumors are rare in children. The prevailing view suggests that bladder tumors in children and young adults are often low-grade or low-malignant-potential papillary tumors with a relatively good prognosis. Moreover, UP in children and young patients remain uncommon 4 – 7 . In somt literature Urothelial bladder cancer (UBC) presenting in 0.003% of the population under 20 years of age 8 。In Stanton ML et al.'s study of 59 young bladder tumor patients, 49 cases were identified as noninvasive papillary transitional cell carcinomas 9 . Blood in the urine is the most common presenting symptom in pediatric and young adult bladder tumor patients; this point has reached a consensus among most studies 10 – 12 . Polat H et al. reported that the most common sites were the lateral walls or trigones of the bladder 10 . Research by Paner GP et al. revealed that tumors are more commonly located in the trigone or at the ureteric orifices of the bladder 11 . Saltsman JA et al. reported that the most common locations were the posterior wall (n = 8; 29%), lateral walls (n = 6; 21%), and trigone (n = 5; 18%) 5 . Although different studies have reported varying rates of site-specific occurrence, the most common sites remain the trigone, lateral walls, and posterior wall, with the cephalic wall being the least common. In this case, the tumor located on the right wall of the bladder was consistent with the statistical distribution described in the aforementioned studies, likely related to the position of the right ureteric orifice. UP are rare benign papillary urothelial tumors. Microscopically, they exhibit broad vascular cores covered by normal urothelium without significant cytological atypia. On imaging, UP often appear as feather-like lesions 13 . Most patients can be diagnosed on the basis of their history and ultrasound findings; however, MRI or CT scans are helpful for assessing the potential malignancy of detected lesions. Because of its non-radioactive nature, MRI should be preferred to CT in the imaging examination of children.The patient in this case has received enhanced CT examination in other hospitals, and bladder color Doppler ultrasound has been completed, which strongly suggests bladder tumor. The surgical indications are clear, and postoperative pathological examination can confirm the diagnosis. Whether to perform MRI before surgery does not determine the next treatment plan, so we did not give the patient MRI related examination. Finally cystoscopy and pyelography are less common in pediatric patients. In terms of treatment, transurethral resection of bladder tumors (TURBT) is the preferred approach, Holmium laser enucleation has advantages in operation time, intraoperative blood loss, postoperative gross hematuria time, bladder irrigation time and postoperative hospital stay compared with traditional resection 14 . Therefore, transurethral laser excision of the bladder tumor was used in the choice of surgical plan for this patient ,The surgical extent should reach the muscle layer, and histopathological examination postoperatively remains the gold standard 12 , 13 . With respect to postoperative intravesical chemotherapy, due to the benign nature of UP, routine bladder instillation therapy is not recommended for most patients. In this case, epirubicin bladder infusion chemotherapy was administered once as a preventive measure prior to definitive histopathological results, and the patient experienced mild symptoms of bladder irritation without secondary hematuria or hepatorenal damage. Currently, there is a paucity of international consensus on postoperative follow-up plans for pediatric bladder cancer patients, the follow-up protocols are primarily extrapolated from adult bladder cancer guidelines, although pathological outcomes in children tend to be less aggressive. However, follow-up remains crucial, as it enables early detection of potential tumor recurrences 5 , 7 , 10 , 12 . Ultrasound imaging is recommended for this purpose because of its efficacy and safety profile. The recurrence rate of UP in pediatric populations has been reported to be lower than that in adults 6 . A study by Karatzas et al. reported no evidence of tumor recurrence at 3, 6, or 12 months in patients who underwent bladder urothelial papilloma excision 15 . Nevertheless, the optimal management approach for such cases remains a matter of debate 12 . In the present case, the patient underwent scheduled postoperative follow-up evaluations at 3 and 6 months. Urinary ultrasound surveillance demonstrated no evidence of bladder tumor recurrence during these assessments. Although cystoscopy provides superior visual characterization of bladder lesions, this modality was not employed in our pediatric patient due to its invasive nature and potential procedural discomfort. The patient maintained normal voiding function throughout the surveillance period. Continued clinical monitoring remains imperative given the limited follow-up duration for evaluating long-term recurrence risk. Regular follow-up examinations are being maintained to monitor for potential disease recurrence. Pediatric bladder tumors are relatively rare, likely due to limited exposure to established carcinogenic factors such as tobacco smoke and industrial chemicals. However, sporadic case reports have documented their occurrence worldwide. Current management is challenged by heterogeneity in tumor classification, diagnostic approaches, and follow-up protocols, precluding the establishment of standardized guidelines. While transurethral resection of bladder tumor (TURBT) has demonstrated efficacy in pediatric cases, the present case raises novel etiological considerations. The patient's chronic habit of chewing on a water-based pen nib suggests possible long-term exposure to chemical dyes as a potential risk factor. Water-based pen ink composition typically includes water, colorants, pigments, and various additives. Of particular concern are low-quality products that may contain unregulated dye components with potential carcinogenic properties. Although this single case cannot establish a definitive causal relationship between water-based pen exposure and UP development, it highlights important safety considerations. Although conclusive evidence establishing a causal relationship between pen chewing and bladder tumorigenesis remains unavailable, the complex chemical composition of these products necessitates stricter regulatory oversight. Furthermore, public health initiatives should be implemented to educate children and adolescents about potential risks associated with habitual exposure to these chemical substances. Conclusions Bladder tumors exhibit low incidence in pediatric populations, with the majority representing benign lesions. While postoperative intravesical chemotherapy is typically unnecessary in these cases, regular surveillance remains crucial. The natural history and optimal management approaches for pediatric bladder tumors necessitate further investigation through long-term follow-up studies to establish evidence-based clinical guidelines. Regarding therapeutic interventions, both transurethral resection of bladder tumor (TURBT) and laser enucleation have shown comparable efficacy in pediatric patients. For diagnostic and follow-up evaluations, ultrasound and MRI serve as the preferred imaging modalities. When clinically indicated and patient tolerance permits, CT and cystoscopy may be considered for postoperative surveillance. Primary prevention strategies should focus on: (1) enhancing awareness of potential risk factors, (2) minimizing exposure to environmental carcinogens, and (3) promoting healthy lifestyle habits among children and adolescents—particularly discouraging behaviors such as chewing water-based pen nibs, which may reduce the incidence of bladder tumors in this population. Declarations Ethical approval and consent to participate The institutional review-board of the Liuyang People’s Hospital approved this study. Patient gave her full consent for publication and written informed consent was obtained from the patient for anonymized information to be published in this article. Consent for publication Informed Consent: Written informed consent was obtained from the patient's legal guardians for publication of this case report. Availability of data and materials Data sharing is not applicable to this article as no datasets were generated or analysed during the current study. Competing interests The authors declare no conflict of interest. Funding Not applicable. Author Contributions Guotao Liao and Meng Zuo wrote the main manuscript text and Guotao Liao prepared figures 1-6. Zhiguo Zhang and Weiwei Cao participated in the review and editing process of the manuscript. All authors reviewed the manuscript. Acknowledgments We would like to express our gratitude to Chanchan Xiao for the language polishing and guidance on this manuscript. References Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015;136(5):E359–86. 10.1002/ijc.29210 . Epub 2014 Oct 9. PMID: 25220842. Kral M, Michalek J, Skarda J, Tichy T, Smakal O, Kodet R, Student V. High-grade urothelial bladder cancer in children: A case report and critical analysis of the literature. 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Urothelial neoplasms in patients 20 years or younger: a clinicopathological analysis using the world health organization 2004 bladder consensus classification. J Urol. 2005;174(05):1976–80. Berrettini A, Castagnetti M, Salerno A, et al. Bladder urothelial neoplasms in pediatric age: experience at three tertiary centers. J Pediatr Urol. 2015;11(01):e261–5. Marinoni F, Destro F, Selvaggio GGO, Riccipetitoni G. Urothelial carcinoma in children: A case series. Bull Cancer. 2018;105(6):556–561. 10.1016/j.bulcan.2018.03.002 . Epub 2018 May 1. PMID: 29724585. Stanton ML, Xiao L, Czerniak BA, Guo CC. Urothelial tumors of the urinary bladder in young patients: a clinicopathologic study of 59 cases. Arch Pathol Lab Med. 2013;137(10):1337–41. 10.5858/arpa.2012-0322-OA . PMID: 24079760; PMCID: PMC3927706. Polat H, Utangac MM, Gulpinar MT, Cift A, Erdogdu IH, Turkcu G. Urothelial neoplasm of the bladder in childhood and adolescence: a rare disease. Int Braz J Urol. 2016 Mar-Apr;42(2):242–6. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7067543","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":514899995,"identity":"7895f721-b8d3-4462-ace5-546a56eb0e76","order_by":0,"name":"Guotao Liao","email":"","orcid":"","institution":"Liuyang People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Guotao","middleName":"","lastName":"Liao","suffix":""},{"id":514899996,"identity":"b207067c-ff08-49ce-b73e-73e94f08a8a8","order_by":1,"name":"Zhiguo Zhang","email":"","orcid":"","institution":"Liuyang People’s 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19:39:53","extension":"png","order_by":33,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":25255,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-7067543/v1/5203e63d174175cc422ab0e7.png"},{"id":91742471,"identity":"752a9bd0-6683-4fed-acf9-17c62cffd02a","added_by":"auto","created_at":"2025-09-19 19:39:52","extension":"xml","order_by":34,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":52234,"visible":true,"origin":"","legend":"","description":"","filename":"2bd6fd63b239428880e119949670d4f01structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7067543/v1/8623323a738b2514468517d6.xml"},{"id":91742540,"identity":"990aceb8-7713-4d0b-a508-ec0fa28732b4","added_by":"auto","created_at":"2025-09-19 19:47:53","extension":"html","order_by":35,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":59590,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7067543/v1/869426d46e74852920b4c616.html"},{"id":91742457,"identity":"228b150f-e2ff-4904-bcc7-fffdc392f5ae","added_by":"auto","created_at":"2025-09-19 19:39:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":89830,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative bladder CT: trigone and posterior wall of bladder\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7067543/v1/e00d012e958cb23aa93486f0.png"},{"id":91742531,"identity":"ecc62c4a-3ee5-47e5-9c40-01adda8540c4","added_by":"auto","created_at":"2025-09-19 19:47:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":82218,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative bladder CT enhancement: Thickening of the bladder wall with enhancement between the right lateral wall\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7067543/v1/a16f045e180146e6589c30bd.png"},{"id":91742534,"identity":"7def27f0-512f-4b9e-979d-3c9686bab74f","added_by":"auto","created_at":"2025-09-19 19:47:52","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":133310,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative color Doppler ultrasound: A mass was seen in the posterior wall of the bladder protruding from the surface of the bladder\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7067543/v1/f01b316ffd6e42a68adc957e.png"},{"id":91742459,"identity":"60e2648d-ba49-48d1-a4c0-ff41164a84e6","added_by":"auto","created_at":"2025-09-19 19:39:52","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":111893,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative color ultrasound blood flow changes: Color ultrasound suggested that the tumor had blood flow signals\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7067543/v1/181e5ee6adb436dac01673ea.png"},{"id":91742473,"identity":"5c20bd33-30f8-4a91-9036-2060300c7a3f","added_by":"auto","created_at":"2025-09-19 19:39:52","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":259828,"visible":true,"origin":"","legend":"\u003cp\u003ePlacement of a 4Fr ureteral catheter after detection of a bladder mas\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7067543/v1/515aefd724f2bc144e67178e.png"},{"id":91742532,"identity":"f11dc911-2e20-4ea9-94a1-0d6f0081d7b2","added_by":"auto","created_at":"2025-09-19 19:47:52","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":248764,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative pathological findings: urothelial papilloma with mild-moderate regional cell dysplasia\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-7067543/v1/6f9ff75b304d39cf98115d81.png"},{"id":91742818,"identity":"d19e4dfc-05fb-42ba-85b4-8992c0a73d5d","added_by":"auto","created_at":"2025-09-19 19:55:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1477491,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7067543/v1/3926f9d9-43ee-487e-bd71-21ba7e0afd48.pdf"},{"id":91742538,"identity":"a0c923fb-152c-42c7-8c58-9fda67e0dd7c","added_by":"auto","created_at":"2025-09-19 19:47:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":763520,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklistEnglish2013.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7067543/v1/6429033a9fab1079a9bf3f31.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Diagnosis and Treatment of a Rare Bladder Urothelial Papilloma in a 9-Year-Old Boy: A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBladder cancer is a common malignant tumor in urology and ranks as the second most frequent urinary system malignancy after prostate cancer. Globally, it is the seventh most diagnosed cancer in men (second only to prostate cancer) and the 13th leading cause of cancer-related mortality\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Its pathogenesis likely involves a complex interplay of physicochemical and biological factors. In China, established risk factors for bladder cancer, as outlined in urological guidelines, include smoking, occupational chemical exposures, chronic urinary tract infections, long-term consumption of arsenic-contaminated water, and *Schistosoma* infection\u003csup\u003e2\u0026ndash;3\u003c/sup\u003e. Alterations in genes such as *HER-2*, *HARS*, and *Bcl-2* in bladder urothelial tissue may contribute to tumorigenesis through diverse mechanisms. Although the molecular pathways underlying bladder cancer development remain incompletely understood, it is widely accepted that any factor promoting uncontrolled proliferation of urothelial cells along with nuclear abnormalities may play a role in disease initiation and progression. Pediatric bladder tumors are exceptionally rare, and due to their young age and limited environmental exposures, children typically lack conventional risk factors such as smoking or prolonged occupational chemical exposure. Consequently, research on the etiology and risk factors of pediatric bladder tumors remains scarce, with limited clinical evidence available. In this case, the child exhibited a habit of chewing on a water-based pen nib, raising the possibility of novel environmental or behavioral risk factors contributing to bladder tumor development in pediatric patients.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eThe patient was a 9-year-old male child who presented for medical care in August 2024. He did not exhibit symptoms such as urinary frequency, dysuria, or lower abdominal discomfort. Blood-tinged urine was also not self-reported by the child; however, he was brought to the clinic because blood-stained underwear was detected by his family members. Initially, the possibility of hematuria was not confirmed by the family upon presentation. upon review of the patient's medical history, no family history of bladder cancer was identified. Potential risk factors including exposure to tobacco smoke, residence in schistosomiasis-endemic regions, hair dye use, and genetic predisposition were all excluded. Notably, the patient reported a chronic habit of chewing on a water-based pen nib.\u003c/p\u003e\u003cp\u003eThe patient initially presented to an external hospital where renal function tests showed normal results. A contrast-enhanced computed tomography (CT) scan of the urinary system (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) revealed an enhancing mass adjacent to the posterior bladder trigone. Based on these clinical and radiographic findings, bladder malignancy was strongly suspected. Subsequently, the patient was referred to our hospital's urology department for further management. Upon admission, we prioritized this case and performed a comprehensive color Doppler ultrasound examination of the urinary system (Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The ultrasound demonstrated a small lesion on the posterior bladder wall with detectable vascular signals, further supporting the diagnosis of bladder tumor.\u003c/p\u003e\u003cp\u003eAfter completing preoperative laboratory investigations, the patient underwent holmium:YAG laser enucleation on hospital day 3. Intraoperative findings revealed a cauliflower-like exophytic lesion measuring 1.2 \u0026times; 1.0 cm located at the junction of the right trigone, posterior wall, and right lateral wall (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Microscopic examination demonstrated a pedunculated tumor with multiple implantation bases, featuring elongated spindle-shaped nuclei with distal enlargement, accompanied by prominent vascular proliferation within and surrounding the tumor. To minimize the risk of iatrogenic injury to the intramural right ureter and subsequent ureteral stricture, a 4Fr ureteral catheter was placed intraoperatively to provide support and guidance during laser ablation. The tumor was completely excised using a holmium:YAG laser (37.5W output power) with dissection extending to the muscularis propria layer. The surgical specimen and intraoperative documentation were reviewed by the family members prior to submission for histopathological analysis. Postoperative management included adjuvant intravesical epirubicin chemotherapy. Both ureteral and Foley catheters were successfully removed on postoperative day 7, with no subsequent reports of voiding dysfunction or flank pain.\u003c/p\u003e\u003cp\u003eHistopathological examination confirmed the final diagnosis of UP with mild-to-moderate atypical hyperplasia (Fig.\u0026nbsp;6). Given the complete surgical excision and favorable pathological findings, adjuvant intravesical chemotherapy was deemed unnecessary. The patient underwent regular follow-up at 3 and 6 months postoperatively, with surveillance bladder ultrasounds showing no evidence of tumor recurrence. Clinical evaluation revealed absence of hematuria, dysuria, or urethral discharge, and renal ultrasonography demonstrated no hydronephrosis bilaterally. The patient maintained an uneventful recovery throughout the follow-up period.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAlthough the incidence of bladder tumors is high in the general population, these tumors are rare in children. The prevailing view suggests that bladder tumors in children and young adults are often low-grade or low-malignant-potential papillary tumors with a relatively good prognosis. Moreover, UP in children and young patients remain uncommon\u003csup\u003e\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. In somt literature Urothelial bladder cancer (UBC) presenting in 0.003% of the population under 20 years of age\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e。In Stanton ML et al.'s study of 59 young bladder tumor patients, 49 cases were identified as noninvasive papillary transitional cell carcinomas\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Blood in the urine is the most common presenting symptom in pediatric and young adult bladder tumor patients; this point has reached a consensus among most studies\u003csup\u003e\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Polat H et al. reported that the most common sites were the lateral walls or trigones of the bladder\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Research by Paner GP et al. revealed that tumors are more commonly located in the trigone or at the ureteric orifices of the bladder\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Saltsman JA et al. reported that the most common locations were the posterior wall (n\u0026thinsp;=\u0026thinsp;8; 29%), lateral walls (n\u0026thinsp;=\u0026thinsp;6; 21%), and trigone (n\u0026thinsp;=\u0026thinsp;5; 18%) \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Although different studies have reported varying rates of site-specific occurrence, the most common sites remain the trigone, lateral walls, and posterior wall, with the cephalic wall being the least common. In this case, the tumor located on the right wall of the bladder was consistent with the statistical distribution described in the aforementioned studies, likely related to the position of the right ureteric orifice.\u003c/p\u003e\u003cp\u003eUP are rare benign papillary urothelial tumors. Microscopically, they exhibit broad vascular cores covered by normal urothelium without significant cytological atypia. On imaging, UP often appear as feather-like lesions\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Most patients can be diagnosed on the basis of their history and ultrasound findings; however, MRI or CT scans are helpful for assessing the potential malignancy of detected lesions. Because of its non-radioactive nature, MRI should be preferred to CT in the imaging examination of children.The patient in this case has received enhanced CT examination in other hospitals, and bladder color Doppler ultrasound has been completed, which strongly suggests bladder tumor. The surgical indications are clear, and postoperative pathological examination can confirm the diagnosis. Whether to perform MRI before surgery does not determine the next treatment plan, so we did not give the patient MRI related examination. Finally cystoscopy and pyelography are less common in pediatric patients.\u003c/p\u003e\u003cp\u003eIn terms of treatment, transurethral resection of bladder tumors (TURBT) is the preferred approach, Holmium laser enucleation has advantages in operation time, intraoperative blood loss, postoperative gross hematuria time, bladder irrigation time and postoperative hospital stay compared with traditional resection\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Therefore, transurethral laser excision of the bladder tumor was used in the choice of surgical plan for this patient ,The surgical extent should reach the muscle layer, and histopathological examination postoperatively remains the gold standard\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. With respect to postoperative intravesical chemotherapy, due to the benign nature of UP, routine bladder instillation therapy is not recommended for most patients. In this case, epirubicin bladder infusion chemotherapy was administered once as a preventive measure prior to definitive histopathological results, and the patient experienced mild symptoms of bladder irritation without secondary hematuria or hepatorenal damage.\u003c/p\u003e\u003cp\u003eCurrently, there is a paucity of international consensus on postoperative follow-up plans for pediatric bladder cancer patients, the follow-up protocols are primarily extrapolated from adult bladder cancer guidelines, although pathological outcomes in children tend to be less aggressive. However, follow-up remains crucial, as it enables early detection of potential tumor recurrences \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Ultrasound imaging is recommended for this purpose because of its efficacy and safety profile. The recurrence rate of UP in pediatric populations has been reported to be lower than that in adults \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. A study by Karatzas et al. reported no evidence of tumor recurrence at 3, 6, or 12 months in patients who underwent bladder urothelial papilloma excision\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Nevertheless, the optimal management approach for such cases remains a matter of debate \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. In the present case, the patient underwent scheduled postoperative follow-up evaluations at 3 and 6 months. Urinary ultrasound surveillance demonstrated no evidence of bladder tumor recurrence during these assessments. Although cystoscopy provides superior visual characterization of bladder lesions, this modality was not employed in our pediatric patient due to its invasive nature and potential procedural discomfort. The patient maintained normal voiding function throughout the surveillance period. Continued clinical monitoring remains imperative given the limited follow-up duration for evaluating long-term recurrence risk. Regular follow-up examinations are being maintained to monitor for potential disease recurrence.\u003c/p\u003e\u003cp\u003ePediatric bladder tumors are relatively rare, likely due to limited exposure to established carcinogenic factors such as tobacco smoke and industrial chemicals. However, sporadic case reports have documented their occurrence worldwide. Current management is challenged by heterogeneity in tumor classification, diagnostic approaches, and follow-up protocols, precluding the establishment of standardized guidelines. While transurethral resection of bladder tumor (TURBT) has demonstrated efficacy in pediatric cases, the present case raises novel etiological considerations. The patient's chronic habit of chewing on a water-based pen nib suggests possible long-term exposure to chemical dyes as a potential risk factor. Water-based pen ink composition typically includes water, colorants, pigments, and various additives. Of particular concern are low-quality products that may contain unregulated dye components with potential carcinogenic properties. Although this single case cannot establish a definitive causal relationship between water-based pen exposure and UP development, it highlights important safety considerations. Although conclusive evidence establishing a causal relationship between pen chewing and bladder tumorigenesis remains unavailable, the complex chemical composition of these products necessitates stricter regulatory oversight. Furthermore, public health initiatives should be implemented to educate children and adolescents about potential risks associated with habitual exposure to these chemical substances.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eBladder tumors exhibit low incidence in pediatric populations, with the majority representing benign lesions. While postoperative intravesical chemotherapy is typically unnecessary in these cases, regular surveillance remains crucial. The natural history and optimal management approaches for pediatric bladder tumors necessitate further investigation through long-term follow-up studies to establish evidence-based clinical guidelines. Regarding therapeutic interventions, both transurethral resection of bladder tumor (TURBT) and laser enucleation have shown comparable efficacy in pediatric patients. For diagnostic and follow-up evaluations, ultrasound and MRI serve as the preferred imaging modalities. When clinically indicated and patient tolerance permits, CT and cystoscopy may be considered for postoperative surveillance. Primary prevention strategies should focus on: (1) enhancing awareness of potential risk factors, (2) minimizing exposure to environmental carcinogens, and (3) promoting healthy lifestyle habits among children and adolescents\u0026mdash;particularly discouraging behaviors such as chewing water-based pen nibs, which may reduce the incidence of bladder tumors in this population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe institutional review-board of the Liuyang People\u0026rsquo;s Hospital approved this study.\u003c/p\u003e\n\u003cp\u003ePatient gave her full consent for publication and written informed consent was obtained from the patient for anonymized information to be published in this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed Consent: Written informed consent was obtained from the patient\u0026apos;s legal guardians for publication of this case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing is not applicable to this article as no datasets were generated or \u0026nbsp; analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGuotao Liao and Meng Zuo wrote the main manuscript text and Guotao Liao prepared figures 1-6. Zhiguo Zhang and Weiwei Cao participated in the review and editing process of the manuscript. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our gratitude to Chanchan Xiao for the language polishing and guidance on this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFerlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015;136(5):E359\u0026ndash;86. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/ijc.29210\u003c/span\u003e\u003cspan address=\"10.1002/ijc.29210\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2014 Oct 9. 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PMID: 30787582; PMCID: PMC6362782.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Bladder tumor, Urothelial papilloma, Pediatric urology, Case report, Risk factors","lastPublishedDoi":"10.21203/rs.3.rs-7067543/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7067543/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBladder tumors are relatively rare in pediatric populations. Given the limited understanding and documentation of such cases, we present this report to describe the diagnosis and management of a rare case of bladder urothelial papilloma (UP) in a 9-year-old male patient. The patient was admitted for evaluation of hematuria discovered by his family. A comprehensive history revealed no known risk factors except for a habit of chewing on a water-based pen nib, which may represent a potential exposure route to chemical dyes. Detailed diagnostic workup confirmed the presence of a bladder mass, leading to transurethral laser resection (TURL) as the treatment modality. Histopathological examination identified UP, and follow-up at 3 and 6 months postoperatively showed no recurrence. This case highlights critical factors in diagnosing and managing pediatric bladder tumors, with special attention to how children's daily habits may impact the condition.\u003c/p\u003e","manuscriptTitle":"Diagnosis and Treatment of a Rare Bladder Urothelial Papilloma in a 9-Year-Old Boy: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-19 19:39:47","doi":"10.21203/rs.3.rs-7067543/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"14780689655006854707214982914945305368","date":"2026-03-26T01:22:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-24T18:43:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"172269595858480326221462690640746491262","date":"2026-03-24T18:25:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"237768610355688887062396336699234090741","date":"2026-03-23T17:15:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-05T20:04:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"291874141688886679918385887039803281661","date":"2025-09-14T20:06:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-12T17:04:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-22T12:48:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-21T15:25:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2025-07-21T15:22:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b75624ad-f45c-4c59-8ecd-d13e91c706ae","owner":[],"postedDate":"September 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-19T19:39:47+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-19 19:39:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7067543","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7067543","identity":"rs-7067543","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}