Overview
Bladder cancer is where a growth of abnormal tissue, known as a tumour, develops in the bladder lining. In some cases, the tumour spreads into the bladder muscle.
The most common symptom of bladder cancer is blood in urine, which is usually painless.
If you notice blood in your urine, even if it comes and goes, you should visit your GP, so the cause can be investigated.
Types of bladder cancer
Once diagnosed, bladder cancer can be classified by how far it has spread.
If the cancerous cells are contained inside the lining of the bladder, doctors describe it as non-muscle-invasive bladder cancer. This is the most common type of bladder cancer (early bladder cancer). This is the most common type of bladder cancer.
When the cancerous cells spread beyond the lining, into the surrounding bladder muscle, it's referred to as muscle-invasive bladder cancer (or invasive bladder cancer). This is less common, but has a higher chance of spreading to other parts of the body.
If bladder cancer has spread to other parts of the body, it's known as advanced or metastatic bladder cancer.
Causes of bladder cancer
Most cases of bladder cancer appear to be caused by exposure to harmful substances, which lead to abnormal changes in the bladder's cells over many years.
Tobacco smoke is a common cause and it's estimated that more than 1 in 3 cases of bladder cancer are caused by smoking.
Contact with certain chemicals previously used in manufacturing is also known to cause bladder cancer. However, these substances have since been banned.
Treating bladder cancer
In cases of non-muscle-invasive bladder cancer, it's usually possible to remove the cancerous cells while leaving the rest of the bladder intact.
This is done using a surgical technique called transurethral resection of a bladder tumour (TURBT). This is followed by a dose of chemotherapy medication directly into the bladder, to reduce the risk of the cancer returning.
In cases with a higher risk of recurrence, medicine known as Bacillus Calmette-Guérin (BCG) may be injected into the bladder to reduce the risk of the cancer returning.
Treatment for high-risk non-muscle-invasive bladder cancer, or muscle-invasive bladder cancer may involve surgically removing the bladder in an operation known as a cystectomy.
Most patients will have a choice of either surgery or a course of radiotherapy.
When the bladder is removed, you'll need another way of collecting your urine. Possible options include making an opening in the abdomen so urine can be passed into an external bag, or constructing a new bladder out of a section of bowel. This will be done at the same time as a cystectomy.
After treatment for all types of bladder cancer, you'll have regular follow-up tests to check for signs of recurrence.
Who is affected?
About 10,000 people are diagnosed with bladder cancer every year and it's the 11th most common cancer in the UK.
The condition is more common in older adults, with most new cases diagnosed in people aged 60 and above.
Bladder cancer is also more common in men than in women, possibly because in the past, men were more likely to smoke and work in the manufacturing industry.
Who can get it
Bladder cancer is caused by changes to the cells of the bladder. It's often linked with exposure to certain chemicals, but the cause isn't always known.
Several factors have been identified that can significantly increase your risk of developing bladder cancer.
Smoking
Smoking is the single biggest risk factor for bladder cancer. This is because tobacco contains cancer-causing (carcinogenic) chemicals.
If you smoke for many years, these chemicals pass into your bloodstream and are filtered by the kidneys into your urine. The bladder is repeatedly exposed to these harmful chemicals, as it acts as a store for urine. This can cause changes to the cells of the bladder lining, which may lead to bladder cancer.
It's estimated that more than a third of all cases of bladder cancer are caused by smoking. People who smoke may be up to 4 times more likely to develop bladder cancer than non-smokers.
Exposure to chemicals
Exposure to certain industrial chemicals is the second biggest risk factor. Previous studies have estimated that this may account for around 25% of cases.
Chemicals known to increase the risk of bladder cancer include:
- aniline dyes
- 2-Naphthylamine
- 4-Aminobiphenyl
- xenylamine
- benzidine
- o-toluidine
Occupations linked to an increased risk of bladder cancer are manufacturing jobs involving:
- dyes
- textiles
- rubbers
- paints
- plastics
- leather tanning
Some non-manufacturing jobs have also been linked to an increased risk of bladder cancer. These include taxi or bus drivers, as a result of their regular exposure to the chemicals present in diesel fumes.
The link between bladder cancer and these types of occupations was discovered in the 1950s and 1960s. Today, strict regulations limit exposure to cancer-causing chemicals.
However, these chemicals are still linked with cases of bladder cancer now, as it can take up to 30 years after initial exposure to the chemicals before the condition starts to develop.
Other risk factors
Other factors that can increase your risk of bladder cancer include:
How bladder cancer spreads
Bladder cancer usually begins in the cells of the bladder lining. In some cases, it may spread into surrounding bladder muscle. If the cancer penetrates this muscle, it can spread to other parts of the body, usually through the lymphatic system.
If bladder cancer spreads to other parts of the body, such as other organs, it's known as metastatic bladder cancer.
Diagnosis
If you have symptoms of bladder cancer, such as blood in your urine, you should see a GP.
Your GP may ask about your symptoms, family history and whether you've been exposed to any possible causes of bladder cancer, such as smoking.
In some cases, your GP may request a urine sample, so it can be tested in a laboratory for traces of blood, bacteria or abnormal cells.
Your GP may also carry out a physical examination of your rectum and vagina, as bladder cancer sometimes causes a noticeable lump that presses against them.
If your doctor suspects bladder cancer, you'll be referred to a hospital for further tests.
Tests and procedures
Some hospitals have specialist clinics for people with blood in their urine (haematuria), while others have specialist urology departments for people with urinary tract problems.
Cystoscopy
If you're referred to a hospital specialist and they think you might have bladder cancer, you should first be offered a cystoscopy.
A specialist will examine the inside of your bladder by passing a thin tube with a camera and light at the end (cystoscope) through your urethra (the tube through which you urinate).
Before having a cystoscopy, a local anaesthetic gel is applied to your urethra so you don't feel any pain. The gel also helps the cystoscope to pass into the urethra more easily.
The procedure usually takes about 5 minutes.
Imaging scans
You may be offered a CT scan or an MRI scan if the specialist feels they need a more detailed picture of your bladder.
An intravenous (IV) urogram may also be used to look at your whole urinary system before or after treatment for bladder cancer.
During this procedure, dye is injected into your bloodstream and X-rays are used to study it as it passes through your urinary system.
Transurethral resection of a bladder tumour (TURBT)
If abnormalities are found in your bladder during a cystoscopy, you should be offered an operation known as TURBT. This is so any abnormal areas of tissue can be removed and tested for cancer (a biopsy).
TURBT is carried out under general anaesthetic.
Sometimes, a sample of the muscle wall of your bladder is also taken to check whether the cancer has spread. This may be a separate operation within 6 weeks of the first biopsy.
You should also be offered a dose of chemotherapy after the operation. This may help to prevent the bladder cancer returning, if the removed cells are found to be cancerous.
Staging and grading
Once these tests have been completed, it should be possible to tell you the grade of the cancer and what stage it is.
Staging is a measurement of how far the cancer has spread. Lower-stage cancers are smaller and have a better chance of successful treatment.
Grading is a measurement of how likely a cancer is to spread. The grade of a cancer is usually described using a number system ranging from G1 to G3. High-grade cancers are more likely to spread than low-grade cancers.
The most widely used staging system for bladder cancer is known as the TNM system, where:
- T stands for how far into the bladder the tumour has grown
- N stands for whether the cancer has spread into nearby lymph nodes
- M stands for whether the cancer has spread into another part of the body (metastasis ), such as the lungs
T stages
The T staging system is as follows:
- TIS or CIS (carcinoma in situ) – a very early high-grade cancer confined to the innermost layer of the bladder lining
- Ta – the cancer is just in the innermost layer of the bladder lining
- T1 – the cancerous cells have started to grow into the connective tissue beyond the bladder lining
Bladder cancer up to the T1 stage is usually called early bladder cancer or non-muscle-invasive bladder cancer.
If the tumour grows larger than this, it's usually called muscle-invasive bladder cancer and is categorised as:
- T2 – the cancer has grown through the connective tissue, into the bladder muscle
- T3 – the cancer has grown through the layer of muscles, into the surrounding layer of fat
If the tumour grows larger than the T3 stage, it's considered to be advanced bladder cancer and is categorised as:
- T4 – the cancer has spread outside the bladder, into surrounding organs
N stages
The N staging system is as follows:
- N0 – there are no cancerous cells in any of your lymph nodes
- N1 – there are cancerous cells in just one of your lymph nodes in your pelvis
- N2 – there are cancerous cells in two or more lymph nodes in your pelvis
- N3 – there are cancerous cells in one or more of your lymph nodes (known as common iliac nodes) deep in your pelvis
M stages
There are only 2 options in the M system:
- M0 – where the cancer hasn't spread to another part of the body
- M1 – where the cancer has spread to another part of the body, such as the bones, lungs or liver
The TNM system can be difficult to understand, so don't be afraid to ask your care team questions about your test results and what they mean for your treatment and outlook.
Find out more:
Treatment
The treatment options for bladder cancer largely depend on how advanced the cancer is.
Treatments usually differ between early stage, non-muscle-invasive bladder cancer and more advanced muscle-invasive bladder cancer.
Your medical team
All hospitals use multidisciplinary teams to treat bladder cancer. These are teams of specialists that work together to make decisions about the best way to proceed with your treatment.
Members of your team may include:
- a urologist – a surgeon specialising in treating conditions affecting the urinary tract, which includes the bladder
- a clinical oncologist – a specialist in chemotherapy and radiotherapy
- a pathologist – a specialist in diseased tissue
- a radiologist – a specialist in detecting disease using imaging techniques
You should be given the contact details for a clinical nurse specialist, who will be in contact with all members of your medical team. They'll be able to answer questions and support you throughout your treatment.
Deciding what treatment is best for you can be difficult. Your medical team will make recommendations, but remember that the final decision is yours.
Before discussing your treatment options, you may find it useful to write a list of questions to ask your team.
Treatment for non-muscle-invasive bladder cancer
If you've been diagnosed with non-muscle-invasive bladder cancer (stages CIS, Ta and T1), your recommended treatment plan depends on the risk of the cancer returning or spreading beyond the lining of your bladder.
This risk is calculated using a series of factors, including:
- the number of tumours present in your bladder
- whether the tumours are larger than 3cm (1 inch) in diameter
- whether you've had bladder cancer before
- the grade of the cancer cells
Low-risk early bladder cancer
Low-risk non-muscle-invasive bladder cancer is treated with transurethral resection of a bladder tumour (TURBT). This procedure may be performed during your first cystoscopy, when tissue samples are taken for testing.
TURBT is carried out under general anaesthetic. The surgeon uses an instrument called a cystoscope to locate the visible tumours and cut them away from the lining of the bladder. The wounds are sealed (cauterised) using a mild electric current, and you may be given a urinary catheter to drain any blood or debris from your bladder over the next few days.
After surgery, you should be given a single dose of chemotherapy, directly into your bladder, using a catheter. The chemotherapy solution is kept in your bladder for around an hour before being drained away.
Most people are able to leave hospital less than 48 hours after having TURBT and are able to resume normal physical activity within 2 weeks.
You should be offered follow-up appointments at 3 and 9 months to check your bladder, using a cystoscopy.
If your cancer returns after 6 months, and is small, you may be offered a treatment called fulguration. This involves using an electric current to destroy the cancer cells.
Intermediate (moderate) risk early bladder cancer
People with intermediate-risk non-muscle-invasive bladder cancer should be offered a course of at least 6 doses of chemotherapy. The liquid is placed directly into your bladder, using a catheter, and kept there for around an hour before being drained away.
You should be offered follow-up appointments at 3, 9 and 18 months, then once every year. At these appointments, your bladder will be checked using a cystoscopy. If your cancer returns within 5 years, you'll be referred back to a specialist urology team.
Some of the chemotherapy medicine may be left in your urine after treatment, which could severely irritate your skin.
It helps if you sit down to urinate and that you're careful not to splash yourself or the toilet seat. Always wash the skin around your genitals with soap and water afterwards.
If you're sexually active, it's important to use a barrier method of contraception, such as a condom. This is because the medicines may be present in your semen or vaginal fluids, which can cause irritation.
You also shouldn't try to get pregnant or father a child while having chemotherapy for bladder cancer, as the medication can increase the risk of having a child with birth defects.
High-risk early bladder cancer
If you have high-risk non-muscle-invasive bladder cancer should be offered a second TURBT operation, within 6 weeks of the initial investigation. A CT scan or an MRI scan may also be required.
Your urologist and clinical nurse specialist will discuss your treatment options with you, which will either be:
- a course of Bacillus Calmette-Guérin (BCG) treatment – using a variant of the BCG vaccine
- an operation to remove your bladder (cystectomy)
The BCG vaccine is passed into your bladder through a catheter and left for 2 hours before being drained away. Most people require weekly treatments over a 6-week period.
Common side effects of BCG include:
- a frequent need to urinate
- pain when urinating
- blood in your urine (haematuria)
- flu-like symptoms, such as tiredness, fever and aching
- urinary tract infections
If BCG treatment doesn't work, or the side effects are too strong, you'll be referred back to a specialist urology team.
You should be offered follow-up appointments every 3 months for the first 2 years, then every 6 months for the next 2 years, then once a year. At these appointments, your bladder will be checked using a cystoscopy.
If you decide to have a cystectomy, your surgeon will need to create an alternative way for urine to leave your body (urinary diversion). Your clinical nurse specialist can discuss your options for the procedure and how the urinary diversion will be created.
After having a cystectomy, you should be offered follow-up appointments including a CT scan at 6 and 12 months, and blood tests once a year. Men require an appointment to check their urethra once a year for 5 years.
Treatment for muscle-invasive bladder cancer
The recommended treatment plan for muscle-invasive bladder cancer depends on how far the cancer has spread.
Your urologist, oncologist and clinical nurse specialist will discuss your treatment options with you, which will either be:
- an operation to remove your bladder (cystectomy)
- radiotherapy with a radiosensitiser
Your oncologist should also discuss the possibility of having chemotherapy before either of these treatments (neoadjuvant therapy), if it's suitable for you.
Radiotherapy with a radiosensitiser
Radiotherapy is given by a machine that beams the radiation at the bladder (external radiotherapy). Sessions are usually given on a daily basis for 5 days a week over the course of 4 to 7 weeks. Each session lasts for about 10 to 15 minutes.
A medicine called a radiosensitiser should also be given alongside radiotherapy for muscle-invasive bladder cancer. This is a medicine which affects the cells of a tumour, to enhance the effect of radiotherapy. It has a much smaller effect on normal tissue.
As well as destroying cancerous cells, radiotherapy can also damage healthy cells, which means it can cause a number of side effects. These include:
- diarrhoea
- cystitis (inflammation of the bladder)
- tightening of the vagina (in women), which can make having sex painful
- erectile dysfunction (in men)
- loss of pubic hair
- tiredness
- difficulty passing urine
Most of these side effects should pass a few weeks after your treatment finishes, although there's a small chance they'll be permanent.
Having radiotherapy directed at your pelvis usually means you'll be infertile (cannot have children).
After having radiotherapy for bladder cancer, you should be offered follow-up appointments every 3 months for the first 2 years, then every 6 months for the next 2 years, and every year after that. At these appointments, your bladder will be checked using a cystoscopy.
You may also be offered CT scans of your chest, abdomen and pelvis after 6 months, 1 year and 2 years. A CT scan of your urinary tract may be offered every year for 5 years.
Surgery and radiotherapy
Your medical team may recommend a specific treatment because of your individual circumstances.
For example, someone with a small bladder or many existing urinary symptoms is better suited to surgery. Someone who has a single bladder tumour with normal bladder function is better suited for treatments that preserve the bladder.
However, your input is also important, so you should discuss which treatment is best for you with your medical team.
There are pros and cons of both surgery and radiotherapy.
The pros of having a radical cystectomy include:
- treatment is carried out in one go
- you won't need regular cystoscopies after treatment, although other less invasive tests may be needed
The cons of having a radical cystectomy include:
- it can take up to 3 months to fully recover
- a risk of general surgical complications, such as pain, infection and bleeding
- a risk of complications from general anaesthetic
- an alternative way of passing urine out of your body needs to be created, which may involve an external bag
- a high risk of erectile dysfunction in men
- after surgery, some women find sex uncomfortable, as their vagina may be smaller, after surgery.
- a small chance of a fatal complication, such as a heart attack, stroke or deep vein thrombosis (DVT)
The pros of having radiotherapy include:
- there's no need to have surgery, which can be important for some people, like those with poor health
- your bladder function may not be affected, as your bladder isn't removed
- less chance of causing erectile dysfunction
The cons of having radiotherapy include:
- needing regular sessions of radiotherapy for 4 to 7 weeks
- short-term side effects, such as diarrhoea, tiredness and inflammation of the bladder (cystitis)
- a small chance of permanently damaging the bladder, which could lead to problems urinating
- some women may have a narrowed vagina, making sex difficult and uncomfortable
Chemotherapy
Sometimes, chemotherapy is used during treatment for muscle-invasive bladder cancer. Instead of medicine being put directly into your bladder, it's put into a vein in your arm. This is called intravenous chemotherapy and can be used:
- before radiotherapy and surgery to shrink the size of any tumours
- in combination with radiotherapy before surgery (chemoradiation)
- to slow the spread of incurable advanced bladder cancer (palliative chemotherapy)
There isn't enough evidence to say whether chemotherapy is an effective treatment when it's given after surgery to prevent the cancer returning. It's usually only used this way as part of a clinical trial.
Chemotherapy is usually given once a week for 2 weeks followed by a week off. This cycle will be repeated for a few months.
As the chemotherapy medicine is being injected into your blood, you'll experience a wider range of side effects than if you were having chemotherapy directly into the bladder. These side effects should stop after the treatment has finished.
Chemotherapy weakens your immune system, making you more vulnerable to infection. It's important to report any symptoms of a potential infection, such as a high temperature, persistent cough or reddening of the skin, to your medical team. Avoid close contact with people who are known to have an infection.
Other side effects of chemotherapy can include:
- nausea
- vomiting
- hair loss
- lack of appetite
- tiredness
Palliative or supportive care
If your cancer is at an advanced stage and can't be cured, your medical team should discuss how the cancer will progress and which treatments are available to ease the symptoms.
You can be referred to a palliative care team, who can provide support and practical help, including pain relief.
Complications
Some treatment for bladder cancer can have a significant impact on your life.
Emotional impact
The emotional impact of living with bladder cancer can be huge. Many people report experiencing a kind of "rollercoaster" effect.
For example, you may feel down at receiving a diagnosis, up when the cancer is removed, and down again as you try to come to terms with the after-effects of your treatment.
This type of emotional disruption can sometimes trigger feelings of depression.
Signs that you may be depressed include:
- having continuous feelings of sadness or hopelessness
- no longer taking pleasure in the things you used to enjoy
Contact your GP for advice if you think you may be depressed. There's a range of treatments for depression, including antidepressants and therapies such as cognitive behavioural therapy (CBT).
Urinary diversion
If your bladder is removed, an alternative way of passing urine out of your body will be created during the operation. This is called urinary diversion.
There are various types of urinary diversion, which are described below. In some cases, you may be able to make a choice based on your personal preferences. However, certain treatment options will not be suitable for everyone.
Your medical team can provide information on the most suitable options for you.
Urostomy
A urostomy is carried out during a radical cystectomy. A small section of the small bowel is removed and connected to your ureters (the two tubes that normally carry urine out of the kidneys).
The surgeon then creates a small hole in the surface of your abdomen and the open end of the removed bowel is placed in this hole, creating an opening known as a stoma.
A special waterproof bag is placed over the stoma to collect urine. A stoma nurse will teach you how to care for your stoma, and how and when to change the bag.
Continent urinary diversion
Continent urinary diversion is similar to a urostomy, but without an external bag. Instead, a section of your bowel is used to create a pouch inside your body that stores urine.
The ureters are connected to the pouch and the pouch is connected to an opening in the abdominal wall. A valve in the opening (stoma) prevents urine leaking out.
The pouch is emptied using a thin, flexible tube (catheter). Most people need to empty their pouch about 4 or 5 times a day.
Bladder reconstruction
In some cases it may be possible to create a new bladder, known as a neobladder.
This involves removing a section of your bowel to make a balloon-like sac, before connecting it to your urethra (the tube that carries urine out of the body) at one end and your ureters at the other end. However, bladder reconstruction isn't suitable for everyone.
You'll be taught how to empty your neobladder by relaxing the muscles in your pelvis, while tightening the muscles in your abdomen at the same time.
Your neobladder won't contain the same types of nerve endings as a real bladder, so you won't get the distinctive sensation that tells you to pass urine. Some people experience a feeling of fullness inside their abdomen, while others have reported they feel like they need to pass wind.
Because of the loss of normal nerve function, most people with a neobladder experience some episodes of urinary incontinence, which usually occurs during the night, while they're asleep.
You may find it useful to empty your neobladder at set times during the day, including before you go to bed, to help prevent incontinence.
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Sexual problems
Erectile dysfunction
Contact your GP or cancer nurse if you lose the ability to obtain or maintain an erection after a radical cystectomy. It may be possible for you to be treated with a type of medicine known as phosphodiesterase type 5 inhibitors (PDE5). PDE5s work by increasing the blood supply to your penis.
PDE5s are sometimes combined with a device called a vacuum pump, which consists of a cylinder connected to a pump. The penis is placed inside the cylinder and the air is pumped out. This creates a vacuum that causes blood to flow into the penis. A rubber ring is then placed around the base of the penis, which allows an erection to be maintained for around 30 minutes.
Narrowing of the vagina
Both radiotherapy and cystectomy can cause a woman's vagina to become shortened and narrowed, which can make penetrative sex painful or difficult.
There are 2 main treatment options available if you have a narrowed vagina. The first is to apply hormonal cream to the area, which should help to increase moisture inside your vagina.
The second is to use vaginal dilators. These are plastic cone-shaped devices of various sizes that are designed to gently stretch your vagina and make it more supple.
It's usually recommended that you use dilators for a 5 to 10 minutes every day, starting with the dilator that fits in easiest first and gradually increasing the size, as your vagina stretches over the following weeks.
Many women find this an embarrassing issue to discuss, but the use of dilators is a well-recognised treatment for narrowing of the vagina. Your specialist cancer nurse should be able to provide more information and advice.
You may find that the more often you have sex, the less painful it becomes. However, it may be several months before you feel emotionally ready to be intimate with a sexual partner.
Find out more about sex and the side effects of cancer treatment from Macmillan Cancer Support.