Blood in your urine is the most common symptom of bladder cancer.

The medical name for this is haematuria and it's usually painless. You may notice streaks of blood in your urine or the blood may turn your urine brown. The blood isn't always noticeable and it may come and go.

Less common symptoms of bladder cancer include:

• a need to urinate on a more frequent basis
• sudden urges to urinate
• a burning sensation when passing urine

If bladder cancer reaches an advanced stage and begins to spread, symptoms can include:

• pelvic pain 
• bone pain
• unintentional weight loss 
• swelling of the legs

When to seek medical advice

If you ever have blood in your urine – even if it comes and goes – you should visit your GP, so the cause can be investigated.

Having blood in your urine doesn't mean you definitely have bladder cancer. There are other, more common, causes including:

• a urinary tract infection, such as cystitis
• a kidney infection
• kidney stones
• urethritis
• an enlarged prostate gland, in men

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.

What is cancer?

Cancer begins with a change (mutation) in the structure of the DNA in cells, which can affect how they grow. This means that cells grow and reproduce uncontrollably, producing a lump of tissue called a tumour.

Increased risk

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. Since then, regulations relating to exposure to cancer-causing chemicals have been made much more rigorous and many of the chemicals listed above have been banned.

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:

• radiotherapy to treat previous cancers near the bladder, such as bowel cancer
• previous treatment with certain chemotherapy medications, such as cyclophosphamide and cisplatin
• having diabetes – bladder cancer is thought to be linked to certain treatments for type 2 diabetes
• having a tube in your bladder (an indwelling catheter) for a long time, because you have nerve damage that has resulted in paralysis
• long-term or repeated urinary tract infections (UTIs)
• long-term bladder stones
• having an early menopause (before the age of 45)
• an untreated infection called schistosomiasis, which is caused by a parasite that lives in fresh water – this is very rare in the UK

How does bladder cancer spread?

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.

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'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.

At the hospital

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.

This procedure allows the specialist to examine the inside of your bladder by passing a cystoscope through your urethra (the tube through which you urinate). A cystoscope is a thin tube with a camera and light at the end.

Before having 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.

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, but 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.

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

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 two 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.

Read more about:

• what cancer stages and grades mean

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
• 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.

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

These treatments are discussed in more detail below.

Low-risk

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 (see diagnosing bladder cancer).

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 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-risk

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 residue of the chemotherapy medication may be left in your urine after treatment, which could severely irritate your skin. It helps if you urinate while sitting down and that you're careful not to splash yourself or the toilet seat. After passing urine, wash the skin around your genitals with soap and water.

If you're sexually active, it's important to use a barrier method of contraception, such as a condom. This is because the medication 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

People with high-risk non-muscle-invasive bladder cancer should be offered a second TURBT operation, within 6 weeks of the initial investigation (see diagnosing bladder cancer). 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.

Read about the complications of bladder cancer surgery for more information about urinary diversion and sexual problems after surgery.

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.

Muscle-invasive bladder cancer

The recommended treatment plan for muscle-invasive bladder cancer depends on how far the cancer has spread. With T2 and T3 bladder cancer, treatment aims to cure the condition if possible, or at least control it for a long time.

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 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
• inflammation of the bladder (cystitis)
• tightening of the vagina (in women), which can make having sex painful
• erectile dysfunction (in men)
• loss of pubic hair
• infertility
• 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 for the rest of your life. However, most people treated for bladder cancer are too old to have children, so this isn't usually a problem.

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 or 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 the use of 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 (estimated at around 90%) as a result of nerve damage
• after surgery, some women may find sex uncomfortable, as their vagina may be smaller
• 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 is often an important consideration for people in poor health
• your bladder function may not be affected, as your bladder isn't removed
• there's less chance of causing erectile dysfunction (around 30%)

The cons of having radiotherapy include:

• you'll require regular sessions of radiotherapy for 4 to 7 weeks
• short-term side effects are common, such as diarrhoea, tiredness and inflammation of the bladder (cystitis)
• a small chance of permanently damaging the bladder, which could lead to problems urinating
• women may experience a narrowed vagina, making sex difficult and uncomfortable

Chemotherapy

In some cases, chemotherapy may be used during treatment for muscle-invasive bladder cancer. Instead of medication 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. See clinical trials for bladder cancer for more information.

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 medication 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

Advanced or metastatic bladder cancer

The recommended treatment plan for locally advanced or metastatic bladder cancer depends on how far the cancer has spread. Your oncologist should discuss your treatment options with you, which may include:

• chemotherapy
• immunotherapy
• treatments to relieve cancer symptoms

Chemotherapy

If you receive a course of chemotherapy, you'll be given a combination of drugs to help relieve the side effects of treatment. Treatment may be stopped if chemotherapy isn't helping, or a second course may be offered.

Immunotherapy

This medicine is for adults with advanced or metastatic bladder cancer. It works by helping the immune system recognise and attack cancer cells.

Relieving cancer symptoms

You may be offered treatment to relieve any cancer symptoms. This may include:

• radiotherapy to treat painful urination, blood in urine, frequently needing to urinate or pain in your pelvic area
• treatment to drain your kidneys, if they become blocked and cause lower back pain

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.

Read more about end of life care.

A diagnosis of bladder cancer, and some treatments for the condition, 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 antidepressant medication and therapies such as cognitive behavioural therapy (CBT).

Read more about coping with cancer.

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.

The Urostomy Association is a UK-based charity that provides information and assistance to people who have recently had, or are about to have, a urostomy.

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 and reconstructing it into 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.

Guy's and St Thomas' NHS Foundation Trust has more information and advice about treatments for bladder cancer.

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.

Read more about treating erectile dysfunction.

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-minute period 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 penetrative sex, the less painful it becomes. However, it may be several months before you feel emotionally ready to be intimate with a sexual partner.

The Macmillan Cancer Support website has some excellent information and a video about cancer and sexuality.