How Bladder Cancer Is Diagnosed: Tests and Staging

Cystoscopy is the gold standard for diagnosing bladder cancer

anatomy of female bladder
SEBASTIAN KAULITZKI/Getty Images

If you or a loved one is being evaluated for bladder cancer, it can be a stressful and overwhelming time. But by learning as much as you can about bladder cancer, including the tests performed to diagnose it, you are already taking an active role in your care.

In addition to gaining knowledge during this time, try to stay as organized as possible, be inquisitive about selecting your bladder cancer team, and attend appointments and tests with a partner or trusted loved one.

Diagnosis of Bladder Cancer Starts With Suspicion

Usually, bladder cancer is suspected by a doctor based on a person's signs and/or symptoms, such as blood in the urine and/or symptoms that are like those seen with a urinary tract infection.

Once suspected, the diagnosis of bladder cancer begins with a thorough discussion with your doctor. In addition to reviewing your symptoms, your doctor may ask you questions about bladder cancer risk factors, like whether you smoke cigarettes (or have a history of it), or whether you have any chemical workplace exposures.

Your doctor will also perform a physical examination including a rectal exam and a prostate exam, if you are a male, or a recto-vaginal exam, if you are a female. The purpose of these exams is to see if anything abnormal can be felt, like a bladder tumor. A urinalysis and urine culture are also done to make sure your symptoms are not from an infection, which is more common than bladder cancer.

In the absence of infection and/or if anything is abnormal with your tests or examination, you will be referred to a urologist, a doctor who specializes in treating diseases of the urinary tract system and male reproductive system.

Tests to Confirm a Diagnosis of Bladder Cancer

When you visits your urologist, he or she will order more sophisticated urine tests and perform a cystoscopy.

Urine Cytology

With urine cytology, a doctor looks under a microscope at a person's urine sample to search for cancer cells. While urine cytology is good at ruling in bladder cancer, it is not a reliable test for ruling out bladder cancer. This is why it is not a good screening test and used mostly in people who already have signs and/or symptoms of bladder cancer.

Urine Tumor Markers

There are a number of tests that can look for certain proteins or markers in the urine that are suspicious for bladder cancer. Like urine cytology, urine tumor markers have their limitations. These tests can miss people with bladder cancer, or the tests may be abnormal in people who do not have cancer, which can lead to anxiety and more unnecessary testing.

Cystoscopy

Along with urine tests, a urologist will perform a cystoscopy, the gold standard test for diagnosing bladder cancer. A cystoscopy is usually performed in your urologist's office under local anesthesia. It is a low-risk procedure, although bleeding and infection can occur. Sometimes cystoscopy is done in an operating room under general anesthesia (meaning you will be asleep).

During a cystoscopy, a urologist will place a cystoscope, a flexible, tube-like instrument that has a light and small video camera, through your urethra and into your bladder (your urethra will be numbed with a gel if you are in your doctor's office).

A sterile solution is then injected into the bladder, so it is stretched and filled. The urologist will then use the cystoscope to visualize the inner lining of your bladder to see if there is a tumor (or multiple tumors) present and if so, where the tumor is, what it looks like, how big it is, and whether there are any mucosal abnormalities.

Transurethral Resection of Bladder Tumor

During the cystoscopy, if a tumor or abnormal area of the bladder is seen, your urologist will take a  biopsy of it. This type of biopsy is called a TURBT (transurethral resection of bladder tumor) and entails the doctor removing the bladder tumor, as well as part of the muscular wall near the tumor.

If no tumor is seen, but the doctor still is worried about cancer (urine cytology may be positive), he may take multiple random bladder biopsies. He will also consider biopsying other parts of the urinary tract system like the urethra and prostate (if male).

Then, a doctor called a pathologist can look at the biopsy under a microscope and see if cancer cells are present. This provides confirmation of a bladder cancer diagnosis.

Once bladder cancer has been confirmed, the grade of the cancer is determined. There are two bladder cancer grades:

  • Low-Grade Bladder Cancer: these cancer cells resemble normal bladder cancer cells.
  • High-Grade Bladder Cancer: these cancer cells do not look like normal bladder cancer cells.

Overall, high-grade bladder cancers are considered more aggressive and therefore harder to treat than low-grade bladder cancers.

CT or MRI

Imaging tests are also needed to evaluate a bladder cancer diagnosis. A CT urogram is an imaging test used to evaluate the kidney, ureters, and bladder. It can provide valuable information about the bladder tumor, like its size, shape, and location, as well as whether the cancer has spread outside of the bladder.

An MRI urogram may also be useful, providing additional information from the CT scan. It is also used in people who are allergic to contrast dye (which is used in a CT scan, but not an MRI).

Other Imaging Tests

Sometimes other imaging tests are ordered, mostly if CT or MRI is unavailable. For example, an IVP (intravenous pyelogram) is a procedure is which a dye is injected into a person's vein, and then an x-ray of the urinary tract system is taken. A kidney and bladder ultrasound does not require contrast dye or radiation, as it uses sound waves to provide images.

A chest x-ray is performed to determine if your cancer has spread to your lungs. A bone scan may be ordered if a person with bladder cancer has bony pain.

Final Step: Bladder Cancer Stage

In addition to the grade of your tumor, your doctor will also determine the stage, or how far the cancer has spread. Overall, the staging and grade of your tumor play a major role in how your bladder cancer is treated, and what your chance of recovery is.

Clinical staging of a person's bladder cancer is generally determined from three things:

  • the biopsy/TURBT results
  • a physical examination that is performed by the doctor while under anesthesia (when the TURBT is performed)
  • imaging studies

Stage 0 is the earliest stage of bladder cancer and means the cancer has not spread through the inner lining of the bladder. Stage IV is the most advanced stage and means the cancer has spread to the pelvis, abdomen, nearby lymph nodes and/or distant sites in the body.

A bladder cancer doctor will use three letters (along with numbers after the letters) to further describe a person's stage:

  • T for Tumor: This feature describes how far the bladder tumor has grown (for example, whether it has grown into the muscular wall of the bladder or not).
  • N for Nodes: This feature describes whether the cancer has spread to any nearby lymph nodes.
  • M for Metastasis: This feature describes whether the cancer has spread to other parts of the body like the liver, bones, or lungs.

The higher the numbers after these letters, the farther along the cancer is, and the more difficult it is to treat.

A Word From Verywell

While the diagnosis of bladder cancer requires time and patience on your part, know that the thoroughness of this process is for your benefit. Once your cancer is diagnosed and staged, your physician can move on to treating it.

Sources:

American Cancer Society. (May 2016). Tests for Bladder Cancer.

Chang et al. Diagnosis and treatment of non-muscle invasive bladder cancer: AUA/SUO guideline. J Urol. 2016 Oct;196(4):1021-9.

Chou R et al. Urinary biomarkers for diagnosis of bladder cancer: A systematic review and meta-analysis. Ann Intern Med. 2015 Dec 15;163(12):922-31.

Lotan Y, Choueiri TK. Patient education: Bladder cancer diagnosis and staging (Beyond the Basics). In: UpToDate, Lerner SP (Ed), UpToDate, Waltham, MA.

Power NE, Izawa J. Comparison of guidelines on non-muscle invasive bladder cancer (EAU, CUA, AUA, NCCN, NICE). Bl Cancer. 2016;2(1):27-36.

Continue Reading