If you have blood in your urine, your GP will ask you for a urine sample.
The sample will be sent to a laboratory so that it can be tested for any abnormal cells that could be due to bladder cancer. This test is known as urinary cytography.
Urinary cytography is not 100% accurate. It can sometimes detect abnormal cells even though there is no cancer present (a false-positive result) or alternatively it can fail to detect abnormal cells when cancer is present (a false-negative result). Therefore, urinary cytography is used to help diagnose bladder cancer and not to provide a definitive diagnosis in itself.
Your urine will also be tested for the presence of bacteria, in case your symptoms are due to an infection.
Your rectum and vagina will also be examined because in some cases of bladder cancer it is possible to feel a noticeable lump that presses against them.
If the results of these initial tests are inconclusive, or if a diagnosis of bladder cancer is suspected, it is likely that you will be referred to a urologist for further testing. A urologist is an expert in treating conditions that affect the urinary system.
Confirming the diagnosis
Computerised tomography (CT) scan
A widely used test to diagnosis bladder cancer is a computerised tomography (CT) scan. A CT scan takes a series of X-rays. These are re-assembled on a computer to make more detailed images of the inside of the body. This can often detect tumours and highlight whether cancer cells have spread.
Cystoscopy
A cystoscopy is a procedure that uses a special instrument, called a cystoscope, to examine the inside of your bladder. The procedure usually takes 5-10 minutes.
A cystoscope is a thin, flexible telescope that is passed into your body and allows the urologist to look inside your bladder.
During a cystoscopy, jelly containing a local anaesthetic is squirted into the opening of your urethra (the tube through which you urinate). As well as working as a painkiller, the jelly helps the cystoscope to pass into the urethra more easily.
The urologist will study the lining of your bladder and urethra to help identify any abnormal areas that could be the result of bladder cancer.
Biopsy
If abnormalities are found in your bladder during a cystoscopy, it is likely that you will be asked to return at a later date so that a sample of bladder tissue can be removed for further testing. This is known as a biopsy.
A more rigid type of cystoscope will be used to take the sample of bladder tissue. This is because it is necessary to pass small surgical instruments up through the cystoscope so that the sample can be removed. The procedure can be uncomfortable, so it will be carried out under general anaesthetic.
Read more about biopsy.
Further testing
If the results of your biopsy show cancerous cells in the lining of your bladder, you may be referred for a series of 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:
magnetic resonance imaging (MRI) scan – a scan that uses radio waves and a magnetic field to produce detailed images of the inside of the body; MRI scans can also be used to check if cancer cells have spread
chest X-ray – this will highlight cancer that has spread to your lungs
Staging
Once these tests have been completed, it should be possible to tell you what stage your bladder cancer is at.
Staging is a measurement of how far the cancer has spread. The lower the stage, the greater the chance of achieving a complete cure. The most widely used staging system for bladder cancer is known as the TNM system, where:
- T stands for how large the tumour has spread into the bladder wall (this is known as tumour invasion)
- 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
Tumour invasion
The T staging system is as follows:
- CIS (carcinoma in situ), where the cancer is at a very early stage with the cancerous cells confined to the inside layer of the bladder lining
- Ta, where the cancerous cells have started to grow through more of the bladder lining
- T1, where the cancerous cells are starting to spread out of the bladder lining and into the surrounding tissue
If the tumour grows larger than the T1 stage, it is considered to be muscle-invasive bladder cancer and is categorised as:
- T2, where the cancer has started to grow into the muscle wall
- T2a, where the cancer has spread into the superficial muscle (the muscles that are closest to the lining of the bladder)
- T2b, where the cancer has spread into the deeper layer of muscles
- T3, where the cancer has spread completely through the layer of muscles and is now spreading into the surrounding layer of fat; this is further divided into:
- T3a, where the cancer in the fat layer can only be seen using a microscope
- T3b, where the cancer in the fat layer can be seen with the naked eye
If the tumour grows larger than the T3 stage, it is considered to be advanced bladder cancer and is categorised as:
- T4, where the cancer has spread outside the bladder; this is further divided into:
- T4a, where the cancer has spread to the prostate (in men) or the womb and vagina (in women)
- T4b, where the cancer has spread to the walls of the abdomen or pelvis
Lymph nodes
The N staging system is as follows:
- N0, where there is no cancerous cells in any of your lymph nodes
- N1, where there are cancerous cells in just one of your lymph nodes in your pelvis
- N2, where there are cancerous cells in two or more lymph nodes in your pelvis
- N3, where there are cancerous cells in one or more of your lymph nodes in your groin
Metastases
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 the implications that they will have on issues such as your outlook, chance of a cure and recommended treatment.
Read more about understanding your test results.
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