Bladder Cancer

Disease Information
Overview +

Bladder Cancer is a serious health risk

  • Bladder Cancer is the 4th most common cancer among males
  • Bladder Cancer is the 10th most common cancer among females
  • Each year in the United States, over 50,000 people develop bladder cancer, of whom more than 12,000 ultimately will die of this disease

Raise Your Awareness
Early recognition of symptoms helps save lives. Early symptoms may include:

  • Blood in the urine
  • More frequent urination
  • Pain on urination

The symptoms above could also indicate problems (less serious) other than bladder cancer.

Who has the greatest risk?

  • Individuals over 60 years of age
  • Cigarette smokers
  • Exposure to certain industrial chemicals (derivatives of arylamines)

Symptoms +

The symptoms for bladder cancer are not specific. Many other diseases, including inflammatory conditions, involving the bladder and kidney may cause similar symptoms. However, since early detection is important in curing bladder cancer, if you have these symptoms, you should bring them to the attention of your doctor.

The most common first symptom of bladder cancer is blood in the urine called hematuria. Hematuria is either visible or microscopic.

  • Gross hematuria describes urine that appears red or brown and can be seen with the naked eye
  • Microscopic hematuria means the red blood cells are visible if a urine sample is examined under a microscope

Irritative urination symptoms may also be associated with bladder cancer and include:

  • pain and burning on urination
  • a sense of incomplete emptying of the bladder after urination and
  • having to urinate more frequently or at shorter intervals

The symptoms above could also indicate problems (less serious) other than bladder cancer.

Anatomy and Physiology +

The bladder is a sac-like organ in the pelvis that stores the urine produced by the kidneys. There are two tubular structures called ureters (one from each kidney) that drain the urine into the bladder. The urethra is the outflow tract of the bladder and connects the bladder to the exterior.

Anatomically, the bladder is the most anterior (closest to the front) organ in the pelvis, located just behind the pelvic bone. Organs closest to the bladder include the rectum (the last part of the colon), which is the most posterior (closest to the back) organ in the pelvis, the prostate gland and seminal vesicles (in males), and the uterus, ovaries and fallopian tubes (in females). In males, the prostate gland and seminal vesicles (organs that contribute secretions in semen) are situated below the bladder and in front of the rectum. In females, the uterus (the womb), ovaries and fallopian tubes are located posterior the bladder and anterior to the rectum.

The bladder itself is made up of four layers. These layers are important landmarks in determining how deeply the tumor has invaded and the ultimate stage of the cancer.

  • Epithelium: The epithelium, which lines the bladder and is in contact with the urine, is referred as transitional epithelium or urothelium. Most bladder cancers originate from the cells of this transitional epithelium. The urethra, ureters and the pelvis of the kidney are also lined by this transitional epithelium, therefore, the same types of cancers seen in the bladder can also occur in these sites.
  • Lamina propria: Under the epithelium is the lamina propria, a layer of connective tissue and blood vessels. Within the lamina propria, there is a thin and often discontinuous layer of smooth muscle called the muscularis mucosae. This superficial layer of smooth muscle is not to be confused with the true muscular layer of the bladder called the muscularis propria or detrusor muscle.
  • Muscularis propria or detrusor muscle: This deep muscle layer consists of thick smooth muscle bundles that form the wall of the bladder. For purposes of staging bladder cancer, the muscularis propria has been divided into a superficial (inner) half and a deep (outer) half.
  • Perivesical soft tissue: This outermost layer consists of fat, fibrous tissue and blood vessels. When the tumor reaches this layer, it is considered out of the bladder.

Diagnosis +

Your doctor has several diagnostic tools to establish a diagnosis of bladder cancer, including radiology, cystoscopy and pathology. However, a definitive diagnosis of bladder cancer can only be made by examining bladder tissue which is performed by a pathologist. The various diagnostic tools are described below.

  • Radiology
    An Intravenous pyelogram (IVP) is a conventional x-ray test using dye to examine the pelves of the kidneys (where urine collects within the kidneys),ureters, and bladder. This x-ray allows visualization of the upper and lower urinary tract to determine the presence of any abnormality.
  • Computed Tomography (CT)
    Essentially a detailed X-ray of the body. CT shows cross-sections of the body and allows your doctor to see details of the anatomy that would not be seen on regular x-ray.
  • Magnetic Resonance Imaging (MRI)
    More sensitive than CT scanning. CT and MRI have the added benefit of detecting enlarged lymph nodes near the tumors, which can suggest that a cancer has spread (metastasized) to the lymph nodes.
  • Cystoscopy
    Cystoscopy is performed by the urologist. It evaluates the bladder by direct visual examination with a specialized instrument call a cystoscope, which is placed in the bladder via the urethra during the examination. The purpose of routine outpatient cystoscopy is to evaluate the lining of the lower urinary tract. If abnormalities such as tumors, stones, or patches of abnormal appearing tissue are discovered during cystoscopy, a biopsy may be taken at that time.
  • Pathology
    The diagnosis of bladder cancer is based on examining cells from the bladder, either from a urine specimen or biopsy of the bladder. Only a pathologist can diagnose if a bladder cancer is present and the type of bladder cancer, by looking at the bladder tissue. The correct diagnosis is critical, as appropriate treatment of bladder cancer is dependant upon the type of cancer seen. The pathology of the bladder is complex and therefore a second opinion is often advisable and can have a major impact in therapy.

    Urine Cytology Comparison
    The diagnosis can sometimes be made by examining urine cytology. A cytopathologist looks at individual cells from the urine, which are spread into a thin layer onto glass microscopic slides. These procedures have the benefit of not requiring an operation or general anesthesia.

    Biopsy of the bladder, performed through the cystoscope, is the more common means of diagnosing these tumors. The pathologist will examine a small sample (a biopsy) of your bladder tissue under a microscope. The pathologist identifies whether the tumor is benign or malignant and the type of tumor. This is essential because tumors of different types behave very differently and require different treatment regimens.

    Biopsy tissue showing bladder cancer

Staging of Bladder Cancer +

Definitive diagnosis of bladder cancer requires surgery to obtain the bladder tissue for the pathologists. The surgeon will also assess the stage of the tumor i.e. how far the disease has spread. The stage of the tumor is the most important indicator of prognosis and overall survival for invasive tumors.

Staging is an assessment of how far the tumor has spread.

  • STAGE 1: The tumor has spread only into loose tissue beneath the lining (lamina propria) but not into the bladder's muscular wall or beyond. No lymph nodes are involved.

  • STAGE 2: Tumor has invaded into the muscle wall (muscularis propria) of the bladder but has not spread to lymph nodes or other sites in the body.

  • STAGE 3: Tumor has invaded through the muscle wall (muscularis propria) of the bladder to involve the soft tissue around the bladder OR has invaded adjacent organs including the prostate, uterus or vagina. No lymph nodes or other distant sites in the body are involved at this stage.

  • STAGE 4: Tumor has extended out of the bladder to invade the pelvic or abdominal wall, but does not involve lymph nodes or other distant sites in the body. OR Tumor has spread to involve lymph nodes and/or other distant sites in the body.

RECURRENT/REFRACTORY - Recurrence means that the tumor has returned after initial therapy. Refractory means that the tumor fails to respond to initial treatment.

In general, the lower the stage of the tumor, the better the prognosis.

Types of Bladder Cancer +

Transitional cell or urothelial carcinoma is the most common type of bladder cancer, accounting for more than 90% all bladder cancers. Urothelial carcinomas are separated clinically into superficial tumors and muscle invasive tumors.

Click the two links below to read more about the topics:

  • Superficial Transitional Tumors
  • Invasive Transitional Tumors
  • Other Types

Treatment +

The treatment of transitional cell or urothelial carcinoma is different for superficial tumors and muscle invasive tumors. Superficial bladder cancers can be managed without cystectomy (removing the bladder), usually by transurethral resection (TUR) with or without adjuvant intravesical chemotherapy. Muscle invasive tumors require cystectomy. The distinction between superficial bladder cancer and muscle invasive bladder cancer is critical for treatment and can only be made by tissue diagnosis by a pathologist.

The Johns Hopkins Medical Institutions is a leader in the treatment of bladder cancer. Our surgeons have extensive experience in performing cystectomies, which is considered a major surgical procedure. Studies have shown that patients undergoing cancer procedures can significantly reduce their risk of operative death by selecting a high-volume hospital (one that does many procedures).

Reference: Hospital volume and surgical mortality in the United States. Birkmeyer JD et al. New England Journal of Medicine 2002 Apr 11;346(15):1128-37

Click the two links below to read more about the topics:

  • Treatment of Superficial Tumors
  • Treatment of Muscle Invasive Tumors

Questions to Ask your Doctor +

Download and Print these questions

If you are in the midst of dealing with Bladder Cancer, you have a lot on your mind and you may have difficulty knowing where to start. Since every patient has a unique case, your doctors are your best source of information and you have every right to ask them questions.

, a clinical social worker at Johns Hopkins, has compiled the following list of questions as a guideline. Here are her suggestions:

If you are meeting with a surgeon or oncologist for the first time, do not be afraid to ask:

  • Have you ever treated a Bladder Cancer patient before?
  • If this is a surgeon, how many surgeries have you performed on Bladder Cancer patients?
  • What has the general outcome of those patients been?
  • Where were you trained? (medical school, residency)
  • Which surgeons did you study under?

At any point in the relationship with your physican, you have the right to ask:

  • What is the diagnosis?
  • What treatments are recommended?
  • Are there other treatment options available that you do not provide?
    (i.e. protocol treatments, herbal therapy, touch therapy, other alternative therapies)
  • What are the benefits of each treatment?
  • What are the side effects of each treatment?
  • What are the medications being prescribed?
    What are they for?
    What are their side effects?
  • Are there any clinical drug trials I can participate in?
  • How should I expect to feel during the treatment(s)?
  • What are the risks of the treatment(s)?
  • Will my diet need to be changed or modified?
  • Will I need to take enzymes, vitamins, etc?

Do not forget to ask about the things that are most important to you:

  • How will this affect my ability to work?
  • Can this treatment be done as an outpatient so that I can spend more time at home with family?
  • Will I have any physical limitations?
  • How will my current lifestyle be changed?

Finally - and most importantly - ask these questions of YOURSELF:

  • Does my doctor appear interested in answering my questions?
  • Or, does my doctor look annoyed when I ask questions, like I'm doubting their expertise or I am holding them up?
  • Do I feel that my doctor cares about my medical outcome?

If you are uncomfortable with the results of some of these questions, you may want to re-evaluate your choice of physician or get a second opinion.