Diagnosis of bladder cancer

If you have symptoms of bladder cancer, such as blood in your urine, you should see your GP.

Your GP may ask about your symptoms, family history and whether you have 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 (see below).

Your GP may also carry out a physical examination of your rectum and vagina because bladder cancer sometimes causes a noticeable lump that presses against them.

If your doctor suspects bladder cancer, they will refer you to a hospital for further tests. Some hospitals have specialist clinics for people with blood in their urine (haematuria), whereas others have specialist urology departments for people with urinary tract problems.

At the hospital

If you are referred to a hospital specialist, there are several tests you may have to check for bladder cancer. These are outlined below.

Urine tests

You may be asked to provide a urine sample, so it can be checked for any infection or abnormal cells.

The test for abnormal cells is called urinary cytology.

Urinary cytology is not 100% accurate. It can sometimes detect abnormal cells even though there is no cancer present (a false-positive result) or it can fail to detect abnormal cells when cancer is present (a false-negative result). Therefore, urinary cytology is used to help diagnose bladder cancer rather than providing a definitive diagnosis.

Cystoscopy

A cystoscopy uses a thin tube with a camera and light at the end, known as a flexible cystoscope, to examine the inside of your bladder. The procedure usually takes about 5 minutes.

During a cystoscopy, a local anaesthetic gel is applied to your urethra (the tube through which you urinate) so you don’t feel any pain. The gel also helps the cystoscope to pass into the urethra more easily.

Biopsy

If abnormalities are found in your bladder during a cystoscopy, it is likely you will be asked to return so a sample of bladder tissue can be removed for further testing. This is known as a biopsy.

A biopsy is often carried out using a procedure known as transurethral resection of a bladder tumour (TURBT). The procedure is carried out under general anaesthetic.

See treating bladder cancer for more information about the TURBT procedure.

Further testing

If the results of your biopsy show cancerous cells in the lining of your bladder, you may need further tests. These will help determine whether the cancer has spread beyond the lining of your bladder and, if so, how far it has spread.

Further tests can include a:

• computerised tomography (CT) scan – a series of X-rays are taken to create a detailed picture of the inside of the body. You may be given an injection or drink of dye beforehand to highlight abnormal areas.
• an intravenous (IV) urogram – after dye is injected into your bloodstream, X-rays are used to study it as it passes through your urinary system.

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.

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-G3. High grade cancers are more likely to spread then low grade cancers. 

Staging is a measurement of how far the cancer has spread. Lower stages cancers are smaller and have a better chance of successful treatment. 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 parts 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 is 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 is 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 is 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) found in your groin

M stages

There are only two options in the M system:

• M0, where the cancer has not 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.

Read more about understanding your test results.