Bladder Cancer Symptoms, Causes, Diagnosis and Treatment

Bladder cancer is a significant health concern that affects many individuals worldwide. Understanding its symptoms, causes, diagnosis and treatment options is crucial for early detection and effective management.

What Is Bladder Cancer? 

Located in the lower part of the abdomen, the bladder is a hollow organ that is part of the urinary system. The bladder’s function is to store urine created by the kidneys. The bladder’s muscle wall stretches as it collects more urine and shrinks to squeeze urine out through the urethra to release it from the body when you urinate (pee). 

Bladder cancer develops when cells in the tissues lining the bladder start to grow in an uncontrolled way, forming malignant (cancerous) tumors. Bladder cancer is also called urothelial carcinoma because the type of cells that line the bladder are urothelial cells. Urothelial cells also line the ureter, part of the kidneys and part of the urethra. Urothelial carcinoma can also develop in these locations. 

Bladder cancer can be slow-growing or fast-growing, and affects men and women. Men are about four times more likely to develop bladder cancer than women, and it is the fourth most common cancer among men. 

For people at average risk of developing bladder cancer, there is no recommended screening, such as there is for certain cancers like breast, cervical and colorectal cancers. 

Other cancers can spread to the bladder. Cancers that most commonly spread to the bladder are prostate, rectal, ovarian, cervical and endometrial (uterine) cancers. However, when cancers spread to the bladder from other areas of the body, they are still considered to be the cancer of origin. For example, prostate cancer that has spread to the bladder is still considered to be prostate cancer. Primary bladder cancer — cancer that starts in the bladder — and cancers that have spread to the bladder from other parts of the body may be treated very differently.

Bladder Cancer Causes and Risk Factors

Several factors can put you at risk for bladder cancer.

Lifestyle

Smoking is an example of a lifestyle habit that can cause bladder cancer. Smoking tobacco for many years is the biggest risk factor for developing bladder cancer. The incidence of bladder cancer in smokers is, on average, three times greater than the incidence among non-smokers.

Smoking for a long time can cause cancer because the carcinogens (cancer-causing chemicals) in tobacco enter your bloodstream, get filtered by your kidneys and pass into your urine. Over time, your bladder is exposed to chemicals that can cause gene changes that lead to cancer.

Environmental Exposure

Besides tobacco smoke, exposure to other cancer-causing materials or chemicals in the environment can increase the rate of somatic gene changes, thus increasing the risk for developing bladder cancer. Arsenic in drinking water is an example of an environmental factor that increases the risk of developing bladder cancer. (Source: American Institute for Cancer Research)

Genetic Changes

Several types of genetic changes develop during a person’s lifetime and are not considered inherited. The changes happen in genes that control the repair of damaged DNA in cells or in genes that control cell growth. This type of genetic change is called a somatic mutation. Common somatic mutations related to bladder cancer include changes in FGFR3, TP53, KDM6A and PIK3CA genes. Research has found that genes controlling cell growth are often missing on chromosome 9 in people who have bladder cancer.

Rarely, you can inherit an increased risk of developing bladder cancer due to changes in certain genes. Gene mutations can be inherited, but it doesn’t mean you will develop bladder cancer.

Genetic and environmental factors account for about 7% of bladder cancer cases.

Additional Factors

In addition to smoking, factors that can increase your risk for developing bladder cancer include:

• Chronic urinary infections or inflammation (conditions that may be connected with long-term use of an in-dwelling urinary catheter)
• Bladder stones (long-term)
• Previous treatment with radiation therapy to organs/tissues near the bladder
• Previous treatment with some chemotherapy drugs
• Some treatments for type 2 diabetes
• Chemical exposure (such as exposure to arsenic or chemicals used in manufacturing of paint, rubber, cloth, dyes, plastics and leather)

Reduce Your Risk of Developing Bladder Cancer

You can’t control all cancer causes or risk factors. But you can make changes to help lower your risk of developing bladder cancer.

• If you smoke tobacco or use other tobacco products, quit.
• Eat a diet rich in fruits and vegetables, especially citrus fruits and cruciferous vegetables.
• Drink plenty of water (use a high-quality filter to remove lead, metals and other contaminants). Water helps the kidneys work more efficiently, and it helps flush contaminants out of the bladder.
• Avoid eating red meat and processed meats, which have been linked to an increased risk of developing bladder and other types of cancer.

Symptoms of Bladder Cancer

Sometimes, bladder cancer can develop without symptoms. When symptoms are present, many are non-specific and can be common to other health problems such as an infection. They don’t necessarily mean you have bladder cancer. Blood in the urine is the most significant bladder cancer symptom. 

While symptoms are the same for men and women, women tend to be diagnosed with bladder cancer at more advanced stages because their symptoms can mimic gynecologic conditions. For instance, women may assume blood in the urine is due to menstruation or changes that occur with menopause. For these reasons, women may delay seeing their doctor, resulting in a diagnosis when bladder cancer is more advanced. 

If you notice any unusual symptoms, contact your doctor right away. 

• Blood in the urine
• Pain when you urinate
• Having to urinate but not being able to
• Having to urinate often
• Lower back pain

Advanced Bladder Cancer Symptoms

Symptoms that may be related to advanced bladder cancer — bladder cancer that has spread (metastasized) outside of the bladder to other organs in the body — include: 

• Bone pain
• Unexplained weight loss
• Swelling in the legs
• Anemia
• Pain in the pelvic area, rectum or anus

Diagnosing Bladder Cancer 

If your doctor suspects you may have bladder cancer, diagnosis will involve taking a thorough medical history, including your family history of cancer. Your doctor will also talk with you about your symptoms and will do a physical exam, which can include a pelvic exam for women. If you have a family history of cancer or a known or suspected genetic mutation that could make you more likely to develop cancer, your doctor may refer you for genetic testing. Depending on the results, we may recommend genetic counseling or a consultation with specialists in the Hereditary Cancer Risk Clinic.

Tests typically include:

• Urine test (urinalysis) to look for infection, abnormal cells and blood
• Cystoscopy, which involves inserting a thin tube with a light and a camera on the end through your urethra to examine the urethra and inside of the bladder. Your doctor may remove tumors if any are found and may take tissue samples (biopsies) of any suspicious areas.

A pathologist will analyze cells from the urine and the tissue biopsy to determine a number of factors that will guide the most appropriate treatment. The analysis will reveal if the tumors are benign or malignant (cancer). It will also tell your care team:

• If type of bladder cancer (if bladder cancer is found)
• The grade
• The stage
• Presence of specific gene mutations (if your doctor orders this test) 

The pathologist’s report provides information that is critical in guiding treatment. Froedtert & MCW pathologists who analyze cells for possible bladder cancer specialize in cancers of the genitourinary system and have special training in understanding the complexities of bladder and other urinary cancers.

Bladder cancer grade (High grade vs low grade): The pathologist can tell how quickly cancer cells are growing and multiplying. High-grade cancer cells grow quickly. Low-grade cells grow more slowly. This information tells your doctor how fast your cancer is likely to spread.

Bladder cancer stage is determined by the pathologist based on whether or not the cancer cells are non-invasive or invasive, the extent of invasion (if invasive), and whether or not the cancer has spread to lymph nodes or to other organs. Bladder cancer stages are:

Source: bcan.org

Types of Bladder Cancer

Non-muscle invasive and muscle invasive are two ways to describe bladder cancer, depending on how far it has spread.

Non-Muscle Invasive Bladder Cancer

Non-muscle invasive bladder cancer means the tumors have not yet grown into the muscle wall of the bladder. It is sometimes called superficial bladder cancer. About 70% of bladder tumors are non-muscle invasive. The earliest of these cancers are confined to the surface of the bladder lining and are almost like warts inside the bladder. 

It may be possible to cure non-muscle invasive bladder cancer, but it depends on many factors, including:

• Type of bladder cancer
• If it is confined to the lining of the bladder
• The size and number of tumors
• If it is considered high grade or low grade
• Stage at diagnosis
• Your age and general health

Although the five-year survival rate for non-invasive bladder cancer is around 93%, it has the potential to recur and requires careful monitoring and regular check-ups by your bladder cancer team.

• Papillary tumors are long, thin growths that arise from the lining of the bladder, extending toward the center of the bladder. They are not always cancerous; some are benign. They can stay confined to the bladder but some papillary tumors are more aggressive and have the potential to spread beyond the lining, through the bladder’s muscle wall to lymph nodes, moving beyond the bladder to other organs. 
   
• Carcinoma in situ, or CIS bladder cancer, is a flat growth on cancerous cells on the surface of the bladder. CIS can go on to invade into the wall of the bladder. About 10% of people diagnosed with bladder cancer have this type. It is always considered high grade because CIS cells are extremely abnormal and divide very quickly. CIS needs to be treated immediately. When treated appropriately, it has a 97% five-year survival rate.
   
• T1 tumors have started to penetrate the lining, growing into a layer underneath the lining called the lamina propria, but they have not yet reached the muscle layer. This is an early cancer but it can grow fast. It must be treated promptly to keep it from invading the muscle wall of the bladder.

Muscle-Invasive Bladder Cancer

Muscle-invasive bladder cancer means the tumors have penetrated the muscle layer of the bladder. From the bladder muscle, tumors can spread beyond the bladder, usually to lymph nodes first and then, to other parts of the body. For people with muscle-invasive bladder cancer, the goal of treatment is to keep the cancer from growing and spreading to other organs.

• Metastatic bladder cancer, also called advanced bladder cancer, has grown through the muscle wall of the bladder and spread to other areas of the body.

Rare Types of Bladder Cancer

Urothelial carcinoma accounts for more than 90% of all bladder cancers, but there are other rare types.

• Squamous cell carcinoma is rare in the U.S., affecting only about 3% to 5% of people who develop bladder cancer. It is usually invasive and is advanced by the time it is diagnosed. Squamous cell carcinoma can happen with long-term irritation of the bladder from an infection or from wearing a catheter in the urethra for a long time. It carries a poor prognosis with around a 30% to 50% five-year survival rate. 
   
• Adenocarcinoma is a very rare type of bladder cancer, representing just .5% to 2% of all cases of bladder cancer. It is typically invasive. Adenocarcinoma can originate from the lining of the bladder, but adenocarcinomas from other locations (such as the colon, prostate gland or other organs) can also spread to the bladder. 
   
• Sarcoma is another very rare type of bladder cancer, representing less than 1% of all bladder cancers. It arises from connective tissues in the body and can develop in the muscle cells of the bladder. Sarcomas of the bladder are very aggressive cancers and affect primarily men. Because bladder sarcoma is typically diagnosed at an advanced stage, it can have a poor prognosis.

Choosing a Treatment Team

Our bladder cancer team is comprised of highly experienced urologic oncologists, urologists who specialize in reconstruction, radiation oncologists who offer non-surgical treatments, medical oncologists, radiologists, pathologists and other vital clinicians. As a group, they are disease-specific and treat a high volume of patients with muscle-invasive and non-muscle invasive bladder cancers. They also perform a high volume of cystectomies and urinary diversions.

Because of their specialized focus, they are also engaged in research to improve bladder cancer care and treatment options and therefore, are always aware of the most current and advanced therapies, including clinical trials.

They meet regularly as a team, so patients have the benefit of multiple experts weighing in on their treatment plan to make sure all treatment options are considered. Care is highly personalized for your best possible outcome.

Preparing for a Bladder Cancer Appointment — Questions to Ask 

To prepare for your bladder cancer appointment, you may want to write down questions for your doctor. Since a bladder cancer diagnosis can be overwhelming, take a friend or family member with you to your appointment so they can take notes for you. Questions to ask your doctor can include:

• What kind of bladder cancer do I have?
• How much experience do you (your team) have in treating this type of bladder cancer?
• What is the stage and grade?
• Has it spread beyond the bladder?
• Is my bladder cancer related to any genetic mutations?
• What treatments do you recommend and why?
• Is there a clinical trial for me?
• What is my prognosis — expected survival rate for my type of cancer?
• If the bladder has to be removed, what are my options for reconstruction?
• What type of support do you offer bladder cancer patients?

Bladder Cancer Treatment

The right bladder cancer treatment for you will depend on your cancer’s grade, stage, type, any genetic mutations and your general health condition. Balancing all of these factors, your doctor and team will come up with treatment that will give you the best possible outcome and quality of life. It’s important that you learn as much as possible about treatment and what to expect. Your cancer team may recommend one or more types of treatment.

Chemotherapy 

If you have invasive bladder cancer, you may receive chemotherapy drugs through an IV before surgery (neoadjuvant) to reduce the size of tumors or after surgery (adjuvant) to eliminate remaining cancer cells and keep your cancer from returning (recurring). Chemotherapy may be given during the time you are receiving radiation therapy if radiation therapy is part of your treatment plan. It also may be given as part of your treatment plan if your bladder cancer is at an advanced stage.

Immunotherapy

Drugs called immune checkpoint inhibitors can be used to help the immune system recognize and eliminate cancer cells. Checkpoints are proteins that can keep the immune system from reacting too much or keep T cells from eliminating cancer cells. Checkpoint inhibitors block these proteins, allowing T cells to do a better job of finding and destroying cancer cells. Pembrolizumab and atezolizumab are two examples of immunotherapy drugs that may be used to treat bladder cancer. As with chemotherapy, immunotherapy can be used alone or in combination with other treatments.

Targeted Therapy

If your bladder cancer is a result of a gene mutation, targeted therapy — a drug like erdafitinib, for example — may be used because it targets cancer cells related to a specific genetic mutation. Other targeted therapies can include antibody drug conjugates, which are specialized chemotherapies designed to target molecules on cancer cells. 

Intravesical Therapy

The surgeon may inject medication directly into the bladder. This is called intravesical therapy. It may be used for early stage bladder tumors that are not muscle invasive. Intravesical therapy is injected through a tube (catheter) that is inserted into the urethra and into the bladder. This is typically completed during a clinic visit. The drug stays local, meaning it stays within the bladder and does not spread throughout the body.  Because of this, it is not effective for cancers that have spread beyond the bladder lining or the layer immediately below the lining. 

Medications use in intravesical therapy may include immune therapy that stimulates the immune system to attack cancer cells. Some chemotherapy drugs can be used in the same way. 

Intravesical therapy may be given one time or weekly for a period of time. How often you receive it will be determined by your doctor, depending on how your cancer responds to treatment. After intravesical therapy, your doctor will ask you not to urinate for about an hour to keep the drug in contact with your bladder lining.

Surgery

Surgery is a commonly used treatment strategy for bladder cancer. There are several types of surgery.

Transurethral Resection of Bladder Tumor (TURBT)

TURBT is used as a diagnostic procedure and may also be used as treatment. Using imaging guidance, the doctor will guide a cystoscope (thin, lighted tube) through the urethra to the inside of the bladder. The tube has an electrified wire loop at the end that the doctor uses to remove tumors or to destroy them with heat (high-energy electricity). It can also seal off blood vessels feeding the tumor to help stop bleeding. Any tissue removed is sent to pathology for evaluation that establishes a diagnosis, grade and stage of the disease. 

This procedure can be repeated if needed and carries minimal risks.

What to Expect

You’ll be instructed to stop taking medications that can increase bleeding for one week before surgery, such as ibuprofen, naproxen or blood thinners.

This procedure is done in the hospital setting. You will be given general, spinal or regional anesthesia sedation so you won’t feel discomfort during the procedure. After a period of time in recovery, you can go home.

After the Procedure

• You may need a catheter inserted into your urethra to help avoid blockages. This is temporary, until bleeding from the surgery has stopped.
• Drink plenty of water to help flush out the bladder
• Avoid vigorous activities
• Avoid lifting heavy objects that cause you to strain until your doctor says it is ok

TURBT Side Effects

After the TURBT procedure, common side effects include the following. Medication and topical gels can help ease discomfort, so ask your doctor.

• Blood in the urine or passing blood clots can continue for several weeks
• Pain and burning when urinating, which can last up to a month
• Bladder spasms
• Bladder irritation
• Frequent need to urinate

If you experience any of the following symptoms, call your doctor right away:

• You can’t urinate
• Fever of 101F with or without chills
• Blood clots in your urine – quarter-sized or larger
• Nausea and vomiting

Cystectomy — Partial or Radical

In a partial cystectomy, your doctor removes part of the bladder. This procedure is an option for some limited scenarios.  You can still urinate normally after a partial cystectomy but you may have to “go” more often because your bladder will be smaller.

In a radical cystectomy, your doctor removes the entire bladder and creates a different way for you to urinate. This is called a urinary diversion. Urinary diversion options include an ileal conduit (bag outside your body), an Indiana pouch (internal pouch that collects urine) or a neobladder (new bladder). Your doctor will discuss these options with you before surgery so you can choose the urinary diversion that will work best for you. The surgery requires general anesthesia and will last four to eight hours.

After surgery, you will recover in the hospital for four to eight days.

Urinary Diversion or Neobladder With Whole Bladder Removal

When the entire bladder is removed, the body still needs a way to eliminate urine. Your surgeon can create this opportunity in a number of ways. Before you decide, be sure to have your treatment team explain each option and its risks and benefits, so you can choose the one that will work the best for you.

• Ileal conduit: To form an ileal conduit, your surgeon will remove a short section of the small intestine (ileum). One end is connected to the ureters that would normally carry urine from the kidneys to the bladder. The other end is connected to a stoma – an opening the surgeon creates in the abdomen. Urine then drains into a bag worn on the outside of the abdomen to collect urine. You can release the urine through a valve at the bottom of the bag. On average, people empty the bag four to five times each day (when it’s one third to one half full) and replace the bag every four or five days. If it is leaking, you will want to replace it immediately.
   
• Indiana pouch: Unlike the ileal conduit, the Indiana pouch does not require an external bag to collect urine. Instead, the surgeon creates an internal pouch for urine. The pouch is made from a portion of the colon and part of the small intestine. Then, the ureters that normally extend from the kidneys to the bladder are connected to the pouch. The Indiana pouch still requires a stoma (opening in the abdomen). Instead of the pouch draining through the stoma into an external bag, you insert a catheter through the stoma into the pouch to drain the urine. Then, the catheter is removed. The pouch can hold 13 to 16 ounces of urine. 
   
• Neobladder: A neobladder is created from a piece of the small intestine. It is connected to the ureters, allowing the kidneys to expel urine and waste materials into the new bladder. The neobladder is also connected to the urethra, allowing you to urinate relatively normally. Using a neobladder is not quite the same as emptying a natural bladder, and you will need training to use your muscles in a different way to expel urine. The neobladder can hold a normal amount of urine until you are ready to urinate. To empty the neobladder, you may need a catheter right after surgery or from time to time.

Support After Bladder Is Removed

After bladder removal (cystectomy), patients often face different challenges and need support for physical, emotional and practical needs. A strong support system that includes your care team, family members and friends is vital for helping you navigate recovery and adjust to new circumstances. Encouraging open communication about needs and feelings can enhance this support network.

• Postsurgery care: You may need help with daily activities at home as you recover from surgery. This includes assistance with moving and walking, caring for your incision and managing pain or discomfort.
• Nutritional support: Guidance from a dietitian can help patients make dietary choices that support recovery.
• Rehabilitation: You may need physical therapy to regain strength and mobility.
• Emotional support and counseling: Professional counseling or therapy can help you cope with feelings of anxiety, depression, or grief related to the loss of the bladder and changes in body image. Our Psycho-Oncology Program is designed to assist our cancer patients.
• Support groups: Connecting with others who have undergone similar experiences can provide comfort and understanding. In-person or online support groups can be a valuable resource.
• Assistance at home: Family and friends can help with household chores, meal preparation and child care, making the transition easier during recovery.
• Transportation: You may need help getting to follow-up appointments or therapy sessions, especially if you are still experiencing fatigue or mobility issues.
• Education: Your care team will provide you with information about living without a bladder, including how to manage urinary diversions like an ileal conduit or neobladder.
• Resources: Access to educational materials, websites or organizations focused on bladder cancer and recovery can empower patients and their families.
• Regular follow-up care: Continuous medical follow-up is essential for monitoring health and managing any potential complications or recurrence of cancer.
• Lifestyle adjustments: Support in making lifestyle changes, such as incorporating exercise and managing stress, can contribute to long-term well-being.

Radiation Therapy for Bladder Cancer

External beam radiation therapy is a good option for select patients who prefer non-surgical management strategies. New techniques with radiation and chemotherapy have made this a highly effective and minimally invasive strategy. It is usually given five days a week for four to seven weeks:

• After surgery for patients with early-stage bladder cancer that does not remove the entire bladder
• When patients prefer non-surgical options
• For bladder cancer that has spread (metastasized) to other areas of the body
• For symptom relief in patients who have advanced-stage bladder cancer

There are many new and advanced ways to deliver radiation therapy for patients with bladder cancer. Hearing about these options is an important step in bladder cancer management. Several new radiation techniques have reduced patient side effects significantly from historically given radiation therapy. Froedtert and the Medical College of Wisconsin offers advanced options such as MRI-guided radiation, along with adaptive radiation therapy that adjusts and accounts for patients’ individual anatomy. 

Let your care team know about any side effects from radiation therapy right away so they can recommend ways to ease them. 

Clinical Trials for Bladder Cancer Treatment

Our physicians are involved in national, multi-center research to find more effective ways to treat bladder cancer. In addition, they create trials that are available only through the Froedtert & MCW Cancer Network. Trials may represent your best treatment or may offer options if you have exhausted standard therapies. Ask your doctor if there is a clinical trial for you.

Learn More About Our Clinical Trials

Support and Care During and After Bladder Cancer Treatment

Our Cancer Sexual Health Program and our Oncodermatology Program can help with sexual dysfunction and treatment-related skin changes. We offer a bladder support group, help with wound care and many other services to help you. 

Visit our cancer support services to learn more and make connections.

Second Opinion for Bladder Cancer

If you would like to learn more about your diagnosis and available treatments, please make an appointment with our Cancer Second Opinion Program. A second opinion provides reassurance that your diagnosis is accurate and that you have explored all treatment options. Appointments are available in-person as well as virtually.