If there is a reason to suspect you might have bladder cancer, the doctor will use one or more methods to find out if this disease is really present. If it is, then the extent of spread (stage) of the disease will also be determined.

Signs and symptoms of bladder cancer

Blood in the urine

In most cases, blood in the urine (hematuria) is the first warning signal of bladder cancer. Sometimes, there is enough blood to change the color of the urine. Depending on the amount of blood, the urine may be very pale yellow-red or, less often, darker red. In other cases, the color of the urine is normal but small amounts of blood can be found by urine tests done because of other symptoms or as part of a general medical checkup.

Blood in the urine does not mean you have bladder cancer. Much more often it is caused by other things, such as infection, benign tumors, stones in the kidney or bladder, or other benign kidney diseases. Blood may be present one day and absent the next, with the urine remaining clear for weeks or months. With bladder cancer, blood eventually reappears. Usually, the early stages of bladder cancer cause bleeding but little or no pain.

Change in bladder habits or irritative symptoms

Having to urinate more often than usual can also be a symptom of bladder cancer. Irritative symptoms, such as dysuria (burning during urination) and urgency (feeling as if you need to go but not being able to) can also be symptoms of bladder cancer. However, these symptoms are also more likely to be caused by a benign condition such as infection, benign tumors, bladder stones, an overactive bladder, or an enlarged prostate.

Medical history and physical exam

The first step is for your doctor to take a complete medical history to check for risk factors and symptoms. A physical exam provides other information about signs of bladder cancer and other health problems. The doctor might examine the rectum and vagina (in women) to determine the size of a bladder tumor and to see if and how far it has spread.

Cystoscopy

If bladder cancer is suspected, doctors will recommend a cystoscopy. For this procedure, a slender tube with a lens and a light (a cystoscope) is placed into the bladder through the urethra. This allows the doctor to look inside the bladder. Cystoscopy can be done in the office or in the operating room. This procedure is performed by a urologist, a specialist in diseases of the urinary system. Usually the first cystoscopy will be done in the doctor's office using a small flexible fiberoptic device. Some sort of local anesthesia may be used to numb the bladder for the procedure. If a general or spinal anesthesia is used, the procedure is done in the operating room. If an area looks abnormal or a growth is seen, it will be biopsied (a small piece of tissue from the area is removed to be examined under the microscope). During cystoscopy, bladder washings may be done for to look for cancer cells. Washings are taken by placing a salt solution into the bladder (through a tube) and then removing the solution for microscopic testing.

Fluorescence cystoscopy may be done along with routine cystoscopy. For this procedure, substances called porphyrins are put into the bladder during cystoscopy. These substances are taken up by cancer cells. Then, when the doctor shines a blue light through the cystoscope, the cells containing the porphyrins will glow (fluoresce). This can allow the doctor to see areas with cancer cells that may have been missed by the white light normally used.

Lab tests

Urine cytology

The urine is examined under a microscope to see if it contains any cancer or pre-cancer cells. Cytology is also done on any bladder washings taken when the cystoscopy was done. Although cytology can help find some cancers, this test is not perfect. Not finding cancer on this test doesn’t always mean you are cancer free.

Urine culture

For a urine culture, a sample of urine is put into a dish in the lab to allow any bacteria that are present to grow. Because it can take time for the bacteria to grow, it may take a few days to get the results of this test. This test is done to make sure that the urine is not infected. Infections and bladder cancers can cause similar symptoms.

Biopsy

When a piece of tissue from an abnormal area is removed to see if it contains cancer cells, the procedure is called a biopsy. The tissue that is removed is sent to the lab so that a pathologist can look at it under the microscope. A pathologist is a doctor who specializes in diagnosing diseases by examining tissues with a microscope.

Bladder biopsies: Bladder biopsy samples are most often obtained during cystoscopy. This allows the doctor to be precise in terms what tissue is removed. A biopsy can show if cancer is present and what type of cancer it is (transitional cell carcinoma, squamous cell carcinoma, adenocarcinoma, etc.). It can also show how deeply the cancer has penetrated into the bladder wall, which is very important in deciding treatment.

Bladder cancers are graded based on how they look under the microscope.

• Low-grade cancers look more like normal bladder tissue. They are also called well-differentiated cancers. These cancers usually have a good prognosis (outlook).

• High-grade cancers look less like normal tissue. These cancers may be called either poorly differentiated or undifferentiated. High-grade cancers are more likely to grow into the bladder wall and to spread outside the bladder. These cancers tend to have a less favorable prognosis.

It is not unusual for people with one bladder cancer to develop more cancers in other areas of the bladder or in the urinary system. For this reason, the doctor may take tissue samples from several different areas of the bladder lining.

Needle biopsies: Although images from tests (see the next section) can suggest the cancer has spread, a biopsy is the only way to be sure. In some cases, these samples are obtained during the surgery to remove the bladder cancer. Another way to get a biopsy sample is to use a needle to take tissue from the abnormal area. This is known as a needle biopsy, and it can allow the doctor to take samples without an operation. Needle biopsies are sometimes done using a CT scan or ultrasound to accurately guide the biopsy needle into the abnormal area.

Tumor marker studies

There are a number of different urine tests that look for specific substances released by bladder cancer cells. These include the test for NMP22 (discussed in the section, “Can bladder cancer be found early?”) Other tests that may be used are the ImmunoCyt test, the BTA stat test, and the UroVysion test. Some doctors find these tests useful, but most feel that cystoscopy is still the best way to find bladder cancer.

Imaging tests

If you are found to have bladder cancer, your doctor may order some of these tests to see if the cancer has spread to tissues near the bladder, nearby lymph nodes, or to distant organs. If an imaging test shows enlarged lymph nodes or other signs of cancer spread, some type of biopsy will be needed to confirm the findings. Samples of tissue are taken from the area that looks abnormal and checked to see if cancer cells are present.

Intravenous pyelogram

An intravenous pyelogram (IVP) is an x-ray of the urinary system taken after injecting a special dye into a vein. This dye is removed from the bloodstream by the kidneys and then passes into the ureters and bladder. This more clearly outlines these organs on x-rays and helps find urinary tract tumors. This procedure is also called intravenous urography.

Retrograde pyelography

For this procedure, a tube (catheter) is placed into the bladder or into a ureter. Then, a dye is injected through the catheter to make the lining of the bladder, ureters, and kidneys easier to see on x-rays. Like IVP, this test can be used to find tumors in the upper part of the urinary tract.

Chest x-ray

A chest x-ray may be done to look for a tumor or a spot on the lungs that might be the spread from a bladder cancer.

Computed tomography (CT)

The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body. Instead of taking one picture, like a conventional x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into an image of a slice of your body (think of a loaf of sliced bread). The machine will take pictures of multiple slices of the part of your body that is being studied.

Before any pictures are taken, you may be asked to drink 1 to 2 pints of a liquid called oral contrast. This helps outline the intestine so that certain areas are not mistaken for tumors. You may also receive an IV line through which a different kind of contrast dye (IV contrast) is injected. This helps better outline structures such as blood vessels in your body.

The injection can cause some flushing (redness and warm feeling that may last hours to days). A few people are allergic to the dye and get hives. Rarely, more serious reactions like trouble breathing and low blood pressure can occur. Medicine can be given to prevent and treat allergic reactions. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays.

CT scans take longer than regular x-rays. You will need to lie still on a table while they are being done. But just like other computerized devices, they are getting faster and your stay might be pleasantly short. The newest CT scanners take only seconds to complete the study. Also, you might feel a bit confined by the ring-like equipment you’re in when the pictures are being taken.

A CT scan can provide precise information about the size, shape, and position of a tumor. It can also help find enlarged lymph nodes that might contain cancer and provide a good picture of your kidneys and bladder.

CT scans can also be used to guide a biopsy needle precisely into a suspected tumor. This is not used to biopsy tumors within the bladder, but is most often used to take tissue samples from areas where the cancer may have spread. For this procedure, called a CT-guided needle biopsy, the patient remains on the CT scanning table while a radiologist advances a biopsy needle toward the location of the tumor. CT scans are repeated until the doctors are confident that the needle is within the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue about ½-inch long and less than 1/8 inch in diameter) is removed and examined under a microscope.

Magnetic resonance imaging scans

This procedure is similar to a CT scan, but uses powerful magnets and radio waves instead of x-rays to take detailed cross-sectional images. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. Not only does this produce cross sectional slices of the body like a CT scanner, it can also produce slices that are parallel with the length of your body. For some scans, a contrast material may be injected into your vein to help see some structures better.

Magnetic resonance imaging (MRI) scans take longer than CT scans -- often up to an hour. Also, most MRI scanners require that you be placed inside a tight tube-like piece of equipment to take the pictures. This is uncomfortable for many people, and can upset people with claustrophobia (fear of enclosed spaces). If you become anxious in tight spaces, speak to your doctor about it before getting an MRI. Also, the machine makes a thumping noise that you may find annoying. Some places will provide headphones with music to block this noise out.

MRI images are particularly useful in finding signs that the cancer has spread outside of the bladder into nearby tissues or lymph nodes. A special type of MRI, the MRI urogram, can be used instead of an IVP to look at the upper part of the urinary system.

MRI scans are also helpful in finding cancer that has spread to the brain or spinal cord.

Ultrasound

Ultrasound uses sound waves to create pictures of internal organs. It can be useful in determining the size of a bladder cancer and whether it has spread beyond the bladder. This test is also known as ultrasonography.

Bone scan

For this procedure, a small amount of a radioactive substance is injected into a vein. This substance builds up in areas of bone containing cancer. A scanner can spot the radioactive deposits. Although bone scans are used to look for cancer spread, abnormal results can also be caused by problems other than cancer, such as infection or arthritis.

Positron emission tomography scan

A positron emission tomography (PET) scan is a test that uses radioactive glucose (sugar) to look for cancer cells. This sugar is injected into the patient's vein. Because cancers use glucose (sugar) at a higher rate than normal tissues, the radioactivity will tend to concentrate in the cancer. A scanner can spot the radioactive deposits. This test can be helpful in spotting small collections of cancer cells that may not be able to be seen on a CT or MRI scan. It may also be able to tell if a tumor is benign or a cancer.

Although PET scans may be used as part of research projects in bladder cancer, they are not yet a standard part of the work-up of patients with bladder cancer.

Last Medical Review: 01/27/2009
Last Revised: 5/13/2009