Bladder cancer

How cancer develops

About bladder cancer

Bladder cancer develops in the lining of your bladder wall. It's caused by the uncontrolled growth of cells. In the UK, more than 10,000 people are diagnosed with bladder cancer each year.

Your bladder is a hollow, muscular, balloon-like organ that collects and stores urine. Urine is produced by your kidneys, which clean your blood by filtering out water and waste products. Urine passes from your kidneys through tubes (called the ureters) into your bladder and then outside your body (through the urethra).

Types of bladder cancer

There are different types of bladder cancer, named after the type of cell the cancer first starts in and the stage of disease (how far it has spread). These are described below.

Cell type

  • Urothelial carcinoma (also known as transitional cell carcinoma, TCC). Nine out of 10 bladder cancers in the UK are of this type. The cancer develops in the top layer of cells that line your bladder wall. This usually happens in response to cancer-causing agents (carcinogens) passing out in your urine.
  • Squamous cell carcinoma (SCC). This type of bladder cancer is the most common worldwide. It develops in response to chronic irritation and sepsis (a severe infection of your whole body in which your bloodstream contains high levels of bacteria), mostly because of infections caused by parasites.
  • Adenocarcinoma. This is a very rare type of bladder cancer that develops in the mucus-producing cells that line your bladder wall.

Disease stage

  • Superficial (non-muscle invasive) bladder cancer. This is when the cancer is only in the bladder lining and hasn't spread into the deeper layers of your bladder wall. It usually appears as a small, mushroom-like growth on the lining of the bladder (called papillary cancer).
  • Invasive bladder cancer. This is when the cancer has spread into the muscle wall of your bladder. Depending on how far it has spread, invasive bladder cancer can be defined as T2, T3 or T4. For more information, see cancer staging and grading.

Symptoms of bladder cancer

The most common symptom of bladder cancer is having blood in your urine. Other symptoms may include having:

  • a burning feeling when you pass urine
  • a need to pass urine frequently and/or urgently
  • pain in your pelvis

If the bladder cancer is more advanced and has spread considerably, you may have additional symptoms such as bone pain.

These symptoms aren't always caused by bladder cancer, but if you have them see your GP.

Causes of bladder cancer

Doctors don't fully understand why bladder cancer develops. However, certain factors increase your risk of getting the disease. These are described below.

  • Smoking triples your risk of bladder cancer. Exposure to second-hand smoke during childhood may also increase your risk.
  • Exposure to certain industrial chemicals, for example those used in printing and textiles, gas and tar manufacturing, and iron and aluminium-processing industries.
  • A long-term infection with the parasitic disease schistosomiasis, which is also known as bilharzia.
  • A long-term or repeated bladder infection.
  • Having certain types of chemotherapy or radiotherapy treatment to your pelvic area.

Diagnosis of bladder cancer

Your GP will ask about your symptoms and examine you. He or she will also usually ask you to take a urine test. You may be referred to a urologist (a doctor who specialises in identifying and treating conditions that affect the urinary system).

You may have the following tests to confirm a diagnosis.

  • Cystoscopy. This procedure is used to look inside your bladder and urinary system. During the procedure, your surgeon may take a biopsy (small sample of tissue), which will be sent to a laboratory for testing to determine the cell type affected and whether it’s benign (not cancerous) or cancerous.
  • CT urogram. This involves taking a CT scan of your urinary tract before and after injection of a dye that shows up your urinary system.
  • Ultrasound, MRI or CT scan. These scans can help doctors check your urinary system to see if the cancer has spread.

Treatment of bladder cancer

Treatment depends on the position and size of the cancer in your bladder and how far it has spread. Your doctor will discuss your treatment options with you.

Non-surgical

Transurethral resection of bladder tumour (TURBT)
TURBT is the main treatment option for early stage bladder cancer that hasn’t spread into your bladder wall. The procedure is carried out using cystoscopy and removes any unusual growths or tumours on your bladder wall. TURBT is usually followed by bladder treatment with mitomycin C or Bacille Calmette-Guérin (BCG) to destroy any remaining cancer cells and reduce the chance of cancer coming back.

Bladder treatment with mitomycin C or Bacille Calmette-Guérin (BCG)
Mitomycin C is a chemotherapy medicine used to destroy cancer cells. BCG is an immunotherapy that contains a weak form of the bacterium Mycobacterium bovis that works by encouraging your immune system to attack cancer cells. Mitomycin C or BCG treatment is usually given after having a TURBT procedure, though sometimes it may be used alone to treat non-muscle invasive bladder cancer.

Surgery

Removing your bladder and surrounding tissues is the main treatment for muscle-invasive bladder cancer. The operation is called a complete or radical cystectomy.

Before surgery, you may have chemotherapy to shrink the tumour. Then, after removing your bladder, your surgeon will create a new area for you to store urine. There are several ways to do this.

  • Bladder reconstruction (neobladder). A new bladder is made using part of your bowel. Your urine drains from your ureters into the new bladder. As you will have lost the nerves that tell you when your bladder is full, you will need to learn how to pass urine through your urethra by using muscle control.
  • Urostomy. Your ureters are connected to a small opening known as a stoma in your abdomen (tummy) using a short piece of your small bowel. A flat, watertight bag is placed over the stoma to collect your urine.
  • Continent urinary diversion. A section of your bowel is used to make a pouch inside your abdomen to collect urine. The pouch is connected to the outside of your body through a stoma, which is kept closed with a valve. You will need to empty the pouch four to five times a day by putting a thin, flexible tube (catheter) into the stoma.

For older people who can’t have surgery, radical radiotherapy may be a more suitable option.

Prevention of bladder cancer

If you smoke, stopping smoking can reduce your risk of developing bladder cancer.

Living with bladder cancer

After treatment for bladder cancer, you will have regular check-ups with your doctor. If you had a urostomy, a stoma nurse at hospital may be able to give you help and advice.

Being diagnosed with cancer can be distressing for you and your family. Specialist cancer doctors and nurses are experts in providing the care and support you need. There are support groups where you can meet people who may have similar experiences to you. Ask your doctor for advice.

Can bladder cancer be detected with a urine test?

Answer

A urine test is usually done to determine if your symptoms are caused by a bladder infection and to check for any blood. Bladder cancer is usually diagnosed by taking a biopsy (small sample of tissue) from your bladder wall. There are some tests in development, but they are not yet available and are still being researched.

Explanation

Bladder cancer is diagnosed by doing a cystoscopy and taking a biopsy from your bladder wall.

There are a number of tests being developed that may make it possible to diagnose bladder cancer from a sample of urine. According to the European Association of Urology, the following three tests are particularly promising.

  • NMP22 (nuclear matrix protein 22). This test checks levels of the protein NMP22 in your urine. NMP22 levels are often higher in the urine of people with early bladder cancer than people with a healthy bladder.
  • UroVysion®. This test checks for changes in cell DNA and may prove useful in detecting high-grade tumours.
  • ImmunoCyt. This test uses three antibodies (proteins made in a laboratory) to look for particular cancer proteins in your urine and may be particularly useful for detecting low-grade tumours.

These tests are still being investigated and aren't available in the UK yet. Even if they do become available, they are unlikely to be used alone to diagnose bladder cancer – a cystoscopy and biopsy will probably still be needed to confirm the result.

Will treatment for invasive bladder cancer affect my sex life?

Answer

Treatment for invasive bladder cancer may result in physical changes that could affect your sex life. In men, the operation to remove the cancer may damage the nerves that control erections and in women, an operation to remove the urethra may shorten or narrow your vagina.

Explanation

For men
Although great care will be taken, there is a risk that the nerves in your pelvis will be damaged during the operation. If you have problems getting an erection after surgery, there are several options that may help.

  • Medicines. Your doctor may prescribe a medicine that you take as a tablet. This can help you to get an erection by increasing the blood flow to your penis. Examples include sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis). The tablets can be taken at various times before sex (for example, sildenafil is taken about one hour beforehand). Alternatively, your doctor may prescribe medicines that you need to inject directly into your penis, or pellets that you insert into the tip of your penis, to give you an erection.
  • Vacuum pumps. These devices draw blood into your penis to create an erection, which is maintained by placing a rubber ring around the base of your penis. After sex, you remove the ring and your blood flows normally again.
  • Penile prostheses. Mechanical devices can also be used to create an erection. You can have an operation to insert flexible rods or thin inflatable cylinders into your penis.

For women
If surgery has shorted or narrowed your vagina, it may help to use a dilator to stretch it. Dilators are metal or plastic objects that are shaped like a tampon. You put them into your vagina for a few minutes every day. Over a few weeks you gradually use larger sizes and this slowly stretches your vagina. Having regular, gentle sex will also have the same effect.

Ask your doctor if you have any concerns about sex after treatment for bladder cancer.

How will having a urostomy affect my everyday life?

Answer

It may take time to get used to having a urostomy (an opening from the ureters, to allow urine to leave your body without passing through your bladder), but most people are able to return to their jobs and everyday activities. Most hospitals have specialist stoma care nurses who can give you advice and support.

Explanation

When you have surgery to remove your bladder, your surgeon will create a new way for you to store urine. It can be done in several ways and one is by having a urostomy. This involves your surgeon removing a small piece of your small bowel and joining one end of the piece of bowel to your ureters and the other end to a small hole cut into the surface of your abdomen (tummy). The hole is called a stoma. The position of the stoma is usually to the right of your tummy button. However, before your operation your surgeon or nurse will help you plan the position of the stoma that best suits you.

After the operation, urine will pass down your ureters, but instead of going into your bladder it will run through the piece of bowel and out onto the surface of your abdomen. A waterproof bag (a urostomy bag) is placed over the stoma to collect your urine. The bag stays in place with glue. You will need to empty the bag as often as you would normally go to toilet to pass urine.

Your nurse will show you how to clean the stoma and change the bags. Modern urostomy bags are very well designed. They shouldn't leak and are hardly noticeable under clothing. You can wear a smaller bag for exercising or a waterproof dressing for swimming.

Talk to your nurse if you have any problems or concerns.