Bladder cancer is one of the most common cancers of the urinary and genital system. It mainly affects men over 60, and the leading risk factor – smoking – is also the easiest to remove.
The disease has one feature that works in the patient’s favour: it usually shows itself early, with blood in the urine, while the tumour is still confined to the lining of the bladder. About three quarters of tumours are superficial when they are found and are treated through the urethra, without removing the bladder – as long as the warning sign is not ignored.
What is bladder cancer
The inside of the bladder is covered with urothelium – a lining that is also found in the renal pelvis, the ureters and the urethra. About nine out of ten tumours arise from the urothelium (urothelial carcinoma); squamous cell carcinoma and adenocarcinoma are rarer.
What matters most for the choice of treatment is how deeply the tumour has grown:
- Superficial (non-muscle-invasive) tumours – confined to the lining and the layer just beneath it. This group also includes carcinoma in situ – a flat but aggressive lesion that is easily missed.
- Muscle-invasive tumours – have grown into the muscle layer of the wall; they need radical treatment.
- Metastatic tumours – have spread to lymph nodes or other organs.
As well as the stage, the grade is determined – low-grade tumours often recur but rarely progress, while high-grade tumours need a more aggressive approach.
Symptoms
- Painless blood in the urine – the most common and most important sign. The bleeding comes and goes and often disappears for weeks, which misleads people into thinking the problem has passed.
- Microscopic haematuria – blood found when the urine is tested, with no visible change in its colour.
- Irritative symptoms – frequent and urgent urination and stinging, especially with carcinoma in situ; these are easily mistaken for cystitis that, however, “does not clear up” with antibiotics.
- At a more advanced stage – pain in the lower back when a ureter is blocked, pelvic pain, weight loss, swollen legs.
Heavy bleeding with clots and being unable to pass urine need immediate help at an emergency department or a call to 112 (the European emergency number). Painless blood in the urine without these signs is not an emergency measured in minutes, but it is a reason to see a urologist within days, not months – more in the article on blood in the urine.
Causes and risk factors
- Smoking – about half of all cases are linked to it; carcinogens from the smoke are excreted in the urine and act directly on the urothelium.
- Occupational exposure to chemicals – aromatic amines and other substances used in the manufacture of paints, rubber, leather and textiles, and in printing and hairdressing.
- Chronic irritation – a long-term catheter, bladder stones, repeated infections, some parasitic infections.
- Previous radiotherapy to the pelvis and some chemotherapy drugs.
- Age, male sex, a family history and arsenic in drinking water.
Diagnosis
With Dr Penev, the investigation starts with a conversation about the nature of the bleeding, smoking, your occupation and other health conditions, followed by an examination. The urine is tested – a routine urine test, a urine culture to rule out infection and cytology to look for cancer cells.
An ultrasound scan with a well-filled bladder shows larger tumours and the state of the kidneys, but it cannot rule out small or flat lesions. The key test is cystoscopy – looking at the inside of the bladder, which in men is usually done with a flexible instrument under local anaesthetic and takes a few minutes. A CT scan with contrast assesses the upper urinary tract, the bladder wall and the lymph nodes.
When a tumour is seen, the next step is transurethral resection of bladder tumour (TURBT) at the Department of Urology at Kaspela University Hospital (UMBAL Kaspela), Plovdiv – under anaesthesia, the tumour is removed through the urethra with an electric loop and sent for histological examination, which determines its type, grade and depth. TURBT is both a diagnostic and a treatment procedure; for high-risk tumours it is repeated after a few weeks.
Treatment
Superficial tumours. After TURBT, the risk of recurrence is reduced by a single instillation of a chemotherapy drug into the bladder within the first few hours. If the risk is higher, a course of bladder instillations follows – chemotherapy or BCG immunotherapy – over months to years. For the highest-risk tumours, and when BCG fails, early removal of the bladder is discussed.
Muscle-invasive tumours. The standard treatment is radical cystectomy – removal of the bladder with the surrounding organs and the pelvic lymph nodes – and a new route for the urine: a stoma made from a segment of bowel, or a new bladder made from bowel and connected to the urethra. In suitable patients chemotherapy is given before the operation, and the operation can also be minimally invasive – Dr Penev has trained in laparoscopic and uro-oncological surgery. For patients who are not fit for surgery, the alternative is bladder-sparing treatment with TURBT, chemotherapy and radiotherapy.
Metastatic disease is treated systemically – with chemotherapy, immunotherapy and targeted drugs – in collaboration with a medical oncologist.
The plan takes into account the stage, the patient’s general health and their wishes. Treatment is followed by long-term follow-up with cystoscopies and imaging – with this tumour, follow-up is part of the treatment, not a formality.
When to see a urologist
With any blood in the urine, even once and without pain; with microscopic haematuria found on a test; with persistent irritative symptoms that do not respond to treatment for infection; with repeated “cystitis” in a man or a smoker. Dr Penev sees patients in Plovdiv and Karlovo and arranges the necessary tests and treatment at Kaspela University Hospital.
Prevention
Stopping smoking is the most effective measure and makes sense at any age. Follow safety measures when working with chemicals, drink enough fluids, and make sure infections and bladder stones are fully treated. If microscopic haematuria is found on a routine urine test, it deserves investigation, even if you have no symptoms.
With bladder cancer, reacting promptly to a single symptom often makes the difference between a short procedure and a major operation. Book an appointment with Dr Penev if you or someone close to you has noticed blood in the urine or has symptoms that do not go away.
Frequently asked questions
Can bladder cancer be cured?
For superficial tumours, which are the majority when the disease is found, treatment with TURBT and bladder instillations gives good results, but the disease tends to come back and follow-up is essential. For invasive tumours the outcome depends on the stage and on timely surgery.
Is cystoscopy painful?
In men a thin flexible instrument and an anaesthetic gel are usually used; in women, a short instrument. You feel brief discomfort and stinging, but the test takes a few minutes and needs no recovery time.
If I stop smoking, does the risk go down?
Yes. The risk starts to fall in the very first years after stopping, and if a tumour has already been treated, giving up cigarettes reduces the chance of recurrence and makes treatment easier to tolerate.
How often is a check cystoscopy done?
The first is usually three months after TURBT. After that the intervals depend on the risk of the tumour – from once a year for low-risk tumours to every three months during the first two years for high-risk ones.
Can the tumour be seen on ultrasound?
Larger tumours are often visible when the bladder is well filled, but small and flat lesions are easily missed. A normal ultrasound does not rule out a tumour, so if there is blood in the urine a cystoscopy is also done.
The information on this website is for general education and does not replace an examination and consultation with a doctor. If you have urgent symptoms, seek medical help immediately or call 112.