Bladder Cancer: Symptoms, Stages & Treatment Options

What Is Bladder Cancer?

Bladder cancer develops when cells in the bladder lining begin to grow uncontrollably, forming tumors. It is the 10th most common cancer worldwide, with approximately 573,000 new cases diagnosed annually. Most bladder cancers begin in the urothelium, the thin layer of cells lining the inside of the bladder.

The bladder is a hollow, muscular organ in the lower abdomen that stores urine produced by the kidneys. The bladder wall consists of several layers, and understanding these layers is crucial for determining how advanced the cancer is and what treatment approach is most appropriate.

The innermost layer is the urothelium (also called transitional epithelium), which directly contacts urine. Beneath this is a thin layer of connective tissue called the lamina propria, followed by a thick layer of muscle called the muscularis propria. The outermost layer consists of fatty tissue that separates the bladder from nearby organs.

Bladder cancer is significantly more common in men than women, with men being 3 to 4 times more likely to develop the disease. The average age at diagnosis is 73 years, and the risk increases substantially after age 50. While bladder cancer is rare before age 40, cases can occur at any age.

Non-Muscle-Invasive Bladder Cancer

The most common type of bladder cancer is non-muscle-invasive bladder cancer (NMIBC), accounting for approximately 75% of all cases at diagnosis. In this type, cancer cells are found only in the urothelium or lamina propria but have not grown into the muscular wall of the bladder.

Non-muscle-invasive bladder cancer generally has an excellent prognosis, with 5-year survival rates exceeding 90%. However, a key characteristic of this type is its tendency to recur. Studies show that 50-70% of patients will experience a recurrence within 5 years, which is why regular surveillance with cystoscopy is essential after initial treatment.

Within non-muscle-invasive bladder cancer, tumors are further classified by their risk of progression. Low-grade tumors (previously called superficial tumors) rarely become invasive, while high-grade tumors and carcinoma in situ (CIS) carry a higher risk of progressing to muscle-invasive disease.

Muscle-Invasive Bladder Cancer

When cancer grows through the urothelium and lamina propria into the muscle layer of the bladder wall, it is classified as muscle-invasive bladder cancer (MIBC). This represents approximately 25% of bladder cancers at initial diagnosis.

Muscle-invasive bladder cancer is more serious because there is a higher risk that cancer cells have spread to lymph nodes or other parts of the body. However, even with this more advanced stage, approximately 50% of patients can be cured with appropriate treatment, which typically involves removing the bladder (cystectomy) along with chemotherapy.

Metastatic Bladder Cancer

In some cases, bladder cancer is not diagnosed until it has already spread (metastasized) to distant parts of the body. The most common sites for bladder cancer metastases include lymph nodes near the bladder, the liver, lungs, and bones.

While metastatic bladder cancer is difficult to cure, treatment can often control the disease for extended periods and significantly improve quality of life. Modern treatments including immunotherapy have improved outcomes for patients with advanced disease.

What Are the Symptoms of Bladder Cancer?

The most common symptom of bladder cancer is blood in the urine (hematuria), which may appear as pink, red, or cola-colored urine. Other symptoms include painful urination, frequent urination, feeling urgent need to urinate, and recurrent urinary tract infections. Many of these symptoms can also be caused by benign conditions, but should always be evaluated.

Bladder cancer symptoms can vary depending on the stage of the disease. Early-stage bladder cancer may cause only subtle symptoms or, in some cases, no symptoms at all. As the cancer grows, symptoms typically become more noticeable. Recognizing these warning signs early is crucial, as early detection significantly improves treatment outcomes.

Blood in the urine is by far the most common presenting symptom, occurring in approximately 80-90% of patients. The blood may be visible to the naked eye (gross hematuria) or detectable only under microscope examination (microscopic hematuria). Importantly, hematuria from bladder cancer is often intermittent, meaning you might have blood in your urine one day but not the next. This can lead some people to delay seeking medical attention, thinking the problem has resolved.

The color of the urine can range from slightly pink to bright red or even dark brown, depending on the amount of blood present. Sometimes blood clots may be visible. It's important to understand that even a single episode of blood in the urine in adults over 50 warrants medical evaluation, as it could indicate bladder cancer or other serious conditions.

Urinary Symptoms

Beyond blood in the urine, bladder cancer can cause various urinary symptoms that affect daily life. These symptoms occur because the tumor can irritate the bladder lining or obstruct normal urine flow.

• Dysuria (painful urination): A burning or stinging sensation when urinating, similar to symptoms of a urinary tract infection
• Frequency: Needing to urinate more often than usual, even when the bladder is not full
• Urgency: Suddenly feeling a strong need to urinate, sometimes with difficulty holding it
• Difficulty urinating: Trouble starting or maintaining a urine stream
• Weak urine stream: Reduced force of urination

These symptoms overlap considerably with other common conditions, particularly urinary tract infections and benign prostatic hyperplasia in men. However, if these symptoms persist despite treatment for other conditions, or if they occur alongside blood in the urine, bladder cancer should be considered.

Symptoms of Advanced Bladder Cancer

When bladder cancer has grown larger or spread beyond the bladder, additional symptoms may develop. These indicate more advanced disease and require prompt medical attention.

• Lower back pain: Particularly on one side, which may indicate the tumor is affecting the kidneys or ureters
• Pelvic pain: Discomfort in the lower abdomen
• Inability to urinate: Complete blockage of urine flow
• Bone pain: If cancer has spread to the bones
• Unintentional weight loss: Losing weight without trying
• Fatigue: Persistent tiredness not relieved by rest
• Loss of appetite: Reduced interest in eating
• Swelling in the feet: May indicate kidney involvement or lymph node spread

When Should You See a Doctor for Bladder Cancer Symptoms?

See a doctor within days if you notice blood in your urine, even if it only occurs once. Seek immediate medical attention if you experience inability to urinate, severe abdominal pain, high fever with urinary symptoms, or blood clots blocking urine flow. Early evaluation of blood in urine is crucial for detecting bladder cancer at a treatable stage.

Many people delay seeking medical attention for blood in urine because it often comes and goes, or because they assume it's due to a minor issue like a urinary tract infection. However, research shows that earlier diagnosis of bladder cancer leads to significantly better outcomes. A study published in the British Journal of Cancer found that patients who waited more than three months to see a doctor after noticing blood in their urine had worse survival rates.

While blood in urine can have many causes other than cancer, such as urinary tract infections, kidney stones, or exercise-induced hematuria, it's important to rule out bladder cancer through proper medical evaluation. This is especially important for individuals over 50 years old, smokers (current or former), and those with occupational exposure to certain chemicals.

Contact a Doctor If You Experience:

• Blood in your urine, even if it only happens once
• Persistent changes in urination lasting more than 2 weeks
• Urinary symptoms that don't improve with infection treatment
• Recurrent urinary tract infections
• Unexplained lower back or pelvic pain

What Causes Bladder Cancer?

Smoking is the leading cause of bladder cancer, responsible for approximately 50% of all cases. Other risk factors include occupational exposure to industrial chemicals, previous radiation therapy to the pelvis, chronic bladder irritation, certain medications, and family history. The risk increases significantly with age, particularly after 50.

Understanding what causes bladder cancer helps explain why certain preventive measures are effective. Bladder cancer develops when the DNA in bladder cells becomes damaged, causing the cells to grow uncontrollably. This damage accumulates over time, which is why bladder cancer is primarily a disease of older adults.

The bladder's unique role in collecting and storing urine makes it particularly vulnerable to carcinogens (cancer-causing substances). When the kidneys filter waste products from the blood, including harmful chemicals from tobacco smoke or industrial exposures, these substances concentrate in the urine and remain in contact with the bladder lining for hours at a time.

Smoking and Bladder Cancer

Tobacco smoking is by far the most significant risk factor for bladder cancer. Smokers are 3 to 4 times more likely to develop bladder cancer compared to non-smokers, and smoking accounts for roughly half of all bladder cancer cases in both men and women.

The carcinogens in tobacco smoke are absorbed into the bloodstream through the lungs, filtered by the kidneys, and concentrated in the urine. These chemicals, including aromatic amines and polycyclic aromatic hydrocarbons, damage the DNA of the cells lining the bladder. The longer someone smokes and the more cigarettes they smoke daily, the higher their risk.

The good news is that quitting smoking reduces your risk. Former smokers have a lower risk of bladder cancer than current smokers, though the risk remains elevated compared to never-smokers for many years. For those diagnosed with bladder cancer, quitting smoking reduces the risk of recurrence and improves treatment outcomes.

Occupational Chemical Exposure

Certain occupations carry an increased risk of bladder cancer due to exposure to industrial chemicals, particularly aromatic amines. Industries and occupations with elevated risk include:

• Dye and rubber manufacturing
• Leather industry
• Textile production
• Paint manufacturing
• Printing industry
• Hairdressing (historical exposure to hair dyes)
• Truck driving and other occupations with diesel exhaust exposure
• Aluminum, steel, and iron workers

Occupational bladder cancer typically develops 20 to 40 years after initial exposure, reflecting the long latency period of the disease. Modern workplace safety regulations have reduced exposure to many of these chemicals, though vigilance remains important.

Other Risk Factors

Beyond smoking and occupational exposure, several other factors can increase bladder cancer risk:

Previous radiation therapy: Radiation treatment for cancers in the pelvic region, such as prostate, rectal, or cervical cancer, increases the risk of developing bladder cancer years or decades later.

Chronic bladder irritation: Long-term urinary catheter use, recurrent urinary tract infections, and bladder stones can cause chronic inflammation that slightly increases bladder cancer risk.

Arsenic in drinking water: In some parts of the world, naturally occurring arsenic in drinking water increases bladder cancer risk. This is less common in countries with modern water treatment systems.

Certain medications: The chemotherapy drug cyclophosphamide and the diabetes medication pioglitazone have been associated with increased bladder cancer risk.

Family history and genetics: Having a parent or sibling with bladder cancer slightly increases your risk. Certain genetic syndromes, such as Lynch syndrome, are also associated with higher bladder cancer risk.

How Is Bladder Cancer Diagnosed?

Bladder cancer is diagnosed through a combination of tests. Cystoscopy (camera examination of the bladder) is the gold standard for diagnosis. Additional tests include urinalysis to check for blood and cancer cells, CT urography for imaging, and biopsy during cystoscopy to confirm the diagnosis and determine the cancer type and stage.

When bladder cancer is suspected based on symptoms or screening findings, doctors use a systematic approach to confirm the diagnosis and determine how far the cancer has spread. This information is essential for planning the most effective treatment. The diagnostic process typically begins with a medical history and physical examination, followed by several specialized tests.

During the initial evaluation, your doctor will ask detailed questions about your symptoms, their duration and pattern, your smoking history, occupational exposures, and family history of cancer. A physical examination may include checking for masses in the lower abdomen or pelvis.

Urine Tests

Urinalysis is often the first test performed. It can detect blood in the urine (even microscopic amounts not visible to the eye) and signs of infection. A urine sample may also be sent for cytology, where the urine is examined under a microscope for cancer cells. While urine cytology is highly specific (positive results strongly suggest cancer), it is not very sensitive for low-grade tumors, meaning a negative result doesn't rule out bladder cancer.

Newer molecular urine tests can detect genetic markers associated with bladder cancer. These tests are more sensitive than traditional cytology but are not yet universally used as they can have false positives.

Cystoscopy

Cystoscopy is the most important diagnostic tool for bladder cancer. During this procedure, a urologist inserts a thin, flexible tube with a camera (cystoscope) through the urethra into the bladder. This allows direct visualization of the bladder lining to identify any tumors, abnormal areas, or other abnormalities.

The procedure typically takes only a few minutes and can be performed in an office setting with local anesthetic gel in the urethra. While some patients experience mild discomfort or a brief burning sensation, most tolerate the procedure well. If suspicious areas are found, a biopsy can be taken during the same procedure.

Imaging Studies

CT urography (also called CT urogram) is the preferred imaging test for evaluating the urinary tract. This specialized CT scan uses intravenous contrast dye to visualize the kidneys, ureters, and bladder in detail. It can detect tumors in the bladder as well as any involvement of the upper urinary tract.

Before the CT urography, you'll be asked to drink plenty of fluids. During the scan, contrast dye is injected through a vein, and multiple images are taken as the dye passes through your urinary system. The procedure takes about 20-40 minutes.

If cancer is confirmed, additional imaging may be needed to determine if it has spread. This might include:

• CT scan of the chest and abdomen: To check for spread to lymph nodes, liver, or lungs
• PET scan: May be used in certain cases to detect metastatic disease
• MRI: Sometimes used to better assess the depth of tumor invasion in the bladder wall
• Bone scan: If bone metastases are suspected

TURBT: Diagnosis and Initial Treatment

When bladder cancer is suspected or confirmed through cystoscopy, the next step is typically a transurethral resection of bladder tumor (TURBT). This procedure serves both diagnostic and therapeutic purposes.

During TURBT, performed under general or spinal anesthesia, the urologist uses a specialized instrument called a resectoscope to remove visible tumors from the bladder wall. The removed tissue is sent to a pathologist who examines it under a microscope to determine:

• The type of bladder cancer (most are urothelial carcinoma)
• The grade of the cancer (how abnormal the cells look)
• The depth of invasion (whether it involves only the lining or has grown into the muscle)

This information is essential for staging the cancer and determining the most appropriate treatment plan. For non-muscle-invasive bladder cancer, TURBT may be the only surgical treatment needed, though additional intravesical therapy is often recommended to reduce recurrence risk.

How Is Bladder Cancer Treated?

Treatment depends on the cancer stage. Non-muscle-invasive bladder cancer is treated with TURBT surgery followed by intravesical therapy (medication instilled into the bladder). Muscle-invasive bladder cancer typically requires radical cystectomy (bladder removal) with chemotherapy. Some patients may be eligible for bladder-sparing treatments using radiation and chemotherapy. Immunotherapy is increasingly used for advanced cases.

Bladder cancer treatment has advanced significantly in recent years, offering patients more options and better outcomes than ever before. The treatment approach depends primarily on the stage of the cancer, its grade, your overall health, and your personal preferences. Treatment decisions are typically made by a multidisciplinary team including urologists, medical oncologists, radiation oncologists, and pathologists.

All treatment discussions should include information about potential side effects, expected recovery time, impact on quality of life, and long-term follow-up requirements. Don't hesitate to ask questions and seek a second opinion if you have any doubts about your treatment plan.

Treatment for Non-Muscle-Invasive Bladder Cancer

For non-muscle-invasive bladder cancer (NMIBC), treatment aims to remove the tumor completely and prevent recurrence or progression to muscle-invasive disease.

TURBT (Transurethral Resection of Bladder Tumor): This is the initial treatment for all non-muscle-invasive bladder cancers. As described in the diagnosis section, the urologist removes visible tumors through the urethra using a specialized instrument. For some low-risk, small tumors, TURBT alone may be sufficient treatment.

Intravesical Therapy: After TURBT, most patients receive medications instilled directly into the bladder to reduce the risk of recurrence and progression. There are two main types:

• Intravesical chemotherapy: Drugs like mitomycin C are instilled into the bladder through a catheter. A single dose immediately after TURBT reduces recurrence risk. Some patients receive weekly treatments for several weeks.
• BCG (Bacillus Calmette-Guérin): This immunotherapy treatment uses weakened bacteria to stimulate the immune system to attack cancer cells. It's the most effective intravesical treatment for high-risk NMIBC. Treatment typically involves weekly instillations for 6 weeks, followed by maintenance treatments over 1-3 years.

During intravesical therapy, the medication is placed in the bladder through a catheter and retained for 1-2 hours before being urinated out. Side effects may include irritation, frequent urination, and flu-like symptoms (especially with BCG), but these are usually temporary.

Treatment for Muscle-Invasive Bladder Cancer

When bladder cancer has invaded the muscle layer, more aggressive treatment is needed. The standard approach for most patients is surgery to remove the bladder, often combined with chemotherapy.

Neoadjuvant Chemotherapy: Most patients with muscle-invasive bladder cancer are recommended to receive chemotherapy before surgery. This typically involves cisplatin-based combination chemotherapy given over 3-4 cycles (approximately 9-12 weeks). Neoadjuvant chemotherapy has been shown to improve survival rates by shrinking the tumor and treating any microscopic cancer cells that may have spread.

Radical Cystectomy: This surgery removes the entire bladder along with nearby lymph nodes. In men, the prostate and seminal vesicles are also removed. In women, the uterus, fallopian tubes, ovaries, and part of the vagina are typically removed. Modern surgical techniques, including robotic-assisted surgery, have reduced recovery time and complications.

When the bladder is removed, a new way to store and eliminate urine must be created (urinary diversion). There are three main options:

• Ileal conduit (urostomy): A piece of intestine is used to create a channel that diverts urine to an opening (stoma) on the abdomen, where it's collected in a bag. This is the most common option.
• Continent cutaneous reservoir: A pouch is created inside the body using intestinal tissue. Urine collects in the pouch and is drained periodically using a catheter through a small stoma.
• Neobladder: A new bladder is created from intestinal tissue and connected to the urethra, allowing patients to urinate relatively normally. This option is suitable for some patients when the urethra can be preserved.

Bladder-Sparing Treatments

For some patients who cannot undergo or prefer to avoid radical cystectomy, bladder-sparing treatments may be an option. This approach combines TURBT with radiation therapy and chemotherapy (trimodal therapy).

Trimodal therapy involves:

1. Maximum TURBT to remove as much visible tumor as possible
2. Radiation therapy to the bladder (usually daily treatments for 4-7 weeks)
3. Concurrent chemotherapy to make cancer cells more sensitive to radiation

This approach can cure some patients while preserving their bladder, though close follow-up with regular cystoscopies is essential. If cancer recurs, salvage cystectomy may still be needed.

Treatment for Metastatic Bladder Cancer

When bladder cancer has spread to distant parts of the body, the goal of treatment shifts from cure to controlling the disease and maintaining quality of life. Treatment options include:

Chemotherapy: Platinum-based chemotherapy combinations remain a cornerstone of treatment for metastatic bladder cancer. Common regimens include gemcitabine plus cisplatin or carboplatin.

Immunotherapy: Immune checkpoint inhibitors have revolutionized treatment for advanced bladder cancer. Drugs like pembrolizumab, atezolizumab, and nivolumab help the immune system recognize and attack cancer cells. These are often used after chemotherapy or for patients who cannot receive chemotherapy.

Targeted Therapy: For patients whose tumors have specific genetic mutations (FGFR alterations), targeted drugs like erdafitinib may be effective.

Radiation Therapy: Can help control symptoms from tumors in specific locations, such as bone metastases causing pain.

What Happens After Bladder Removal?

After bladder removal (cystectomy), a new way to collect and eliminate urine is created using urinary diversion. The three main options are ileal conduit (external bag), continent reservoir (internal pouch with catheter drainage), or neobladder (new bladder allowing near-normal urination). Most patients learn to manage their urinary diversion successfully and return to normal daily activities.

Having your bladder removed is a significant life change that requires adjustment, but with proper support and training, most people adapt well and maintain good quality of life. Before surgery, you'll meet with a specialized nurse (stoma therapist or urology nurse specialist) who will explain your options and help you prepare for life after surgery.

The recovery period after radical cystectomy typically requires 7-14 days in the hospital, though this varies based on the surgical approach (open vs. robotic) and individual factors. Full recovery at home usually takes 6-12 weeks. During this time, you'll learn to care for your urinary diversion.

Living with a Urostomy (Ileal Conduit)

If you have an ileal conduit, urine continuously drains through a stoma (small opening) on your abdomen into an external collection bag. The bag is waterproof and discrete under clothing. You'll learn to empty the bag when it's about one-third full and change the entire system every few days.

With proper care, there is minimal risk of leakage or odor. Modern urostomy supplies are designed for comfort and reliability. Most people with urostomies can:

• Return to work and normal activities
• Exercise and participate in sports (including swimming)
• Travel without restriction
• Maintain intimate relationships

Living with a Neobladder

If you received a neobladder, you'll urinate through your urethra similarly to before surgery. However, the new bladder doesn't have the same nerve signals as your original bladder, so you won't feel the typical urge to urinate. Instead, you'll need to urinate on a schedule (every 3-4 hours during the day and once at night).

Some people with neobladders experience urinary incontinence, particularly at night, which often improves over time with pelvic floor exercises. You may also need to learn self-catheterization to empty the neobladder completely.

Follow-Up Care After Cystectomy

Regular follow-up appointments are essential after bladder removal to monitor for cancer recurrence and manage any complications. A typical follow-up schedule includes:

• Physical examination and blood tests every 3-4 months for the first 2 years
• CT scans every 3-6 months initially, then less frequently
• Monitoring of kidney function
• Assessment of the urinary diversion

How Does Bladder Cancer Affect Daily Life?

Bladder cancer and its treatment can affect many aspects of life, including urinary function, sexual health, emotional wellbeing, and daily activities. The impact varies based on treatment type and individual factors. Support is available to help manage physical symptoms, emotional challenges, and practical concerns. Most people adjust well over time.

A bladder cancer diagnosis and its treatment journey can be challenging, but understanding what to expect and knowing that support is available can help you cope. The effects on daily life depend largely on the type and extent of treatment you receive.

Fatigue and Energy Levels

Fatigue is one of the most common side effects during and after cancer treatment. It may result from the cancer itself, surgery, chemotherapy, or radiation therapy. Unlike normal tiredness, cancer-related fatigue isn't fully relieved by rest.

Strategies to manage fatigue include:

• Take several short rest breaks rather than one long nap
• Engage in light physical activity, which paradoxically can reduce fatigue
• Prioritize activities and accept help with non-essential tasks
• Eat nutritious foods and stay hydrated
• Maintain good sleep habits

Sexual Health

Bladder cancer treatment can affect sexual function in both men and women. Understanding these effects can help you prepare and seek appropriate support.

For men: Radical cystectomy typically removes the prostate and may affect nerves responsible for erections. Erectile dysfunction is common but can often be managed with medications, devices, or implants. The ability to have orgasms is usually preserved, though ejaculation is no longer possible after surgery.

For women: Surgery may remove part of the vagina and affect vaginal sensation. The vagina may be shorter or tighter. Hormone changes after removal of ovaries can cause vaginal dryness and discomfort during intercourse. These issues can often be managed with lubricants, vaginal dilators, and hormone therapy.

Open communication with your partner and healthcare team is important. Sexual counseling and specialized support are available if needed.

Emotional Wellbeing

It's normal to experience a range of emotions after a bladder cancer diagnosis, including fear, anxiety, sadness, anger, and uncertainty. Some people experience depression that may require professional support.

Helpful coping strategies include:

• Talking to family, friends, or a counselor about your feelings
• Joining a bladder cancer support group (in-person or online)
• Staying physically active within your capabilities
• Practicing stress-reduction techniques like meditation or deep breathing
• Maintaining normal routines as much as possible
• Seeking professional help if depression or anxiety becomes severe

Most people find that emotional distress peaks around the time of diagnosis and treatment, then gradually improves as they adjust to their new normal.

Can Bladder Cancer Be Prevented?

While not all bladder cancer can be prevented, you can significantly reduce your risk by not smoking, avoiding tobacco in all forms, limiting exposure to industrial chemicals, drinking plenty of fluids, and eating a healthy diet rich in fruits and vegetables. For smokers, quitting is the single most important step to reduce bladder cancer risk.

Prevention strategies focus on reducing exposure to known risk factors and maintaining overall health. Given that smoking causes approximately half of all bladder cancer cases, tobacco cessation is by far the most impactful preventive measure.

Stop Smoking

If you smoke, quitting is the best thing you can do to reduce your bladder cancer risk. The benefits begin quickly after quitting, and the risk continues to decrease over time. Even after many years of smoking, quitting is beneficial. Resources to help you quit include:

• Nicotine replacement therapy (patches, gum, lozenges)
• Prescription medications (varenicline, bupropion)
• Counseling and support groups
• Smartphone apps and telephone quit lines

Workplace Safety

If you work with chemicals that increase bladder cancer risk, follow all safety guidelines:

• Use appropriate protective equipment
• Follow safe handling procedures
• Ensure adequate ventilation
• Participate in workplace health monitoring programs

Lifestyle Factors

While the evidence is less strong than for smoking, some lifestyle factors may help reduce bladder cancer risk:

• Stay hydrated: Drinking plenty of fluids may dilute carcinogens in urine and reduce contact time with the bladder lining
• Eat fruits and vegetables: A diet rich in plant foods provides antioxidants that may help protect against cancer
• Maintain a healthy weight: Obesity has been linked to several cancers, though the link with bladder cancer is less clear