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 color 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 is not a sure sign of bladder cancer. It may also be caused by infections of the kidneys, bladder, or urethra, other benign kidney diseases, benign tumors of the kidney, bladder or ureter, and kidney or bladder stones. 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 irratative symptoms: Having to urinate more often than usual or having a feeling of needing to go but not being able to is also a symptom of bladder cancer. Rarely, people with bladder cancer notice burning during urination. However, these symptoms can also be caused by benign conditions such as an infection or 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. A cystoscope is a slender tube with a lens and a light. It is placed into the bladder through the urethra. It permits the doctor to view the inside of the bladder. This can be done in the office by a urologist, a specialist in diseases of the urinary system. Usually the first cystoscopy will be with a small flexible fiberoptic device. Some sort of local anesthesia is used such as an anesthetic gel, but it can be general or spinal. If suspicious areas or growths are seen, a small piece of tissue is removed and examined (biopsy). Also at this time washings will be done for cytology (see below)

Fluorescence cystoscopy may be used at the time of cystoscopy. Substances, called porphyrins, are taken up by cancer cells. They glow (fluoresce) when exposed to blue light. The doctor doing the cystoscopy will instill the porphyrins into the bladder and then shine the blue light through the cystoscope. This may “light up” cancer cells that may have been missed by the white light normally used.

Laboratory Tests to Diagnose Bladder Cancer

Urine cytology: The urine is examined under a microscope to look for cancerous or precancerous cells. Cytology will also be done on bladder washings taken at the time of cystoscopy. Bladder washing samples are taken by placing a salt solution into the bladder through a catheter (tube) and then removing the solution for microscopic testing. If the test does not find cancer, this doesn’t mean there isn’t any there. The test can sometimes fail to find cancer.

Urine culture: A urine culture is done to rule out an infection. Infections and bladder cancers can sometimes cause similar symptoms. A sample of urine is tested in the lab to see if bacteria are present. It may take 48 to 72 hours to get the results of this test.

Biopsy: A sample of bladder tissue is removed from a suspicious area or growth, using instruments operated through the cystoscope. The sample is examined under the microscope by a pathologist, a doctor who specialized in diagnosing diseases by examining tissues with a microscope. The biopsy procedure can identify bladder cancers and tell what type of cancer (urothelial carcinoma, squamous cell carcinoma, adenocarcinoma, etc.) is present. It can also tell how deeply the cancer has penetrated, which is very important in deciding treatment.

Bladder cancers are graded, from 1 to 4, based on how they look under the microscope.

Low-grade (1) cancers look more like normal bladder tissue. They usually have a good prognosis. These are called well-differentiated cancers.

Grade 2 cancers are called moderately differentiated.

High-grade (3-4) cancers look less like normal tissue. They are more likely to invade the bladder wall and to spread outside the bladder and tend to be associated with a less favorable prognosis. These cancers are called either poorly differentiated or undifferentiated.

It is not unusual for people with one bladder cancer to develop additional cancers in other areas of the bladder or elsewhere in the urinary system. For this reason, the doctor may biopsy several different areas of the bladder lining.

Bladder tumor marker studies: These are chemical or immunologic (using antibodies) tests to find specific substances released by bladder cancer cells into the urine such as NMP22 discussed in the section, "Can Bladder Cancer Be Found Early?" Another commonly used test is the ImmunoCyt test. This is another test for cancer-related substances in the urine and may be more sensitive than cytology for certain cancers. Other tests include the BTA stat test, and the UroVysion test which looks at the DNA of the cells in bladder washings. Some doctors find these tests useful, but most feel more research is needed before they should be used routinely. For more information, see the section, "What's New in Bladder Cancer Research and Treatment?"

Imaging Tests

Intravenous pyelogram (IVP): In this procedure, also known as intravenous urography an x-ray is taken after injecting a dye through a vein into the bloodstream. This dye reaches the kidneys, ureters, and bladder and more clearly outlines these organs on x-rays. This is important because the blood in the urine may come from anywhere in the urinary tract, not just the bladder.

Retrograde pyelography: Like the IVP, this test uses special dye to make the lining of the bladder, ureters, and kidneys easier to see on x-rays. The difference is that in retrograde pyelography the dye is injected through a catheter placed with a cystoscope into the ureter rather than into a vein.

Chest x-ray: A chest x-ray is done to look for any mass or spot on the lungs that might be a metastatic tumor, if it is suspected that the bladder cancer has spread distantly.

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. Often after the first set of pictures is taken you will receive an intravenous injection of a "dye" or radiocontrast agent that helps better outline structures in your body. A second set of pictures is then taken.

CT scans take longer than regular x-rays and 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 youÂ’re in when the pictures are being taken.

The contrast "dye" is injected through an IV line. Some people are allergic to the dye and get hives, a flushed feeling, or, rarely, more serious reactions like trouble breathing and low blood pressure. Be sure to tell your doctor if you have ever had a reaction to any contrast material used for x-rays. If you have, you may need medicine before you can have such an injection during your test.

You may also be asked to drink a contrast solution. This helps outline your intestine if your doctor is looking at organs in your abdomen. The CT scan will provide precise information about the size, shape, and position of a tumor, and can help find enlarged lymph nodes that might contain cancer. It also provides a good picture of your kidneys and bladder.

Magnetic resonance imaging (MRI) 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.

If your doctor suspects that the cancer has spread beyond the bladder, MRI scans are sometimes used to find cancer in tissues next to the bladder, in nearby lymph nodes, or in distant organs. In such cases, either a CT or MRI scan may be used.

A contrast material might be injected just as with CT scans but is used less often. MRI scans take longer – often up to an hour. Also, you have to be placed inside a tube-like piece of equipment, which is confining and can upset people with claustrophobia (fear of enclosed spaces). The machine makes a thumping noise that you may find annoying. Some places will provide headphones with music to block this out. MRI images are particularly useful in examining pelvic tumors such as bladder cancers that have begun to spread outside the bladder. MRI scans are also helpful in finding cancer that has spread to the brain or spinal cord.

Ultrasound: This test, also known as ultrasonography, uses sound waves to create "echoes" of internal organs. The pattern of echoes reflected by tissues can be useful in determining the size of a bladder cancer and whether it has spread beyond the bladder.

Bone scans: In this imaging test, a small amount of a radioactive substance is injected into a vein. This substance accumulates in areas of bone where the cancer has spread. These areas can then be looked at with a special camera. However, other cancers and some non-cancerous bone diseases can also cause abnormal bone scan results.

Positron Emission Tomography (PET) scans: PET scanning is a technique that uses radioactive substances to show areas of cancer that may not otherwise be seen on more usual tests such as CT scan or MRI. It may also be able to distinguish benign tumors or masses from cancerous ones.

Although PET scans are being used as part of research projects in bladder cancer, it is not yet certain how valuable they are in helping to manage the care of patients with bladder cancer.

Revised: 08/08/2006