How Bladder Cancer Is Diagnosed

The primary tests used to diagnose bladder cancer include cystoscopy, urine cytology, imaging scans like MRI and CT scans, as well as a physical examination and discussion of symptoms with a healthcare provider. For women, the diagnostic process also includes a recto-vaginal exam, and for men, diagnosis involves a rectal exam and a prostate exam.

Being evaluated for bladder cancer can be stressful and overwhelming. Read on to learn more about the process and the tests used to diagnose this form of cancer.

Pre-Diagnosis

A diagnosis of bladder cancer begins with a thorough discussion with your healthcare provider. In addition to reviewing your symptoms, your healthcare provider 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 exposures in the workplace.

Your healthcare provider will also perform a physical examination. For men, that includes a rectal exam and a prostate exam; for women, a recto-vaginal exam is conducted. 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 healthcare provider who specializes in treating diseases of the urinary tract system (and male reproductive system).

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Lab Tests

When you visit your urologist, they will order more sophisticated testing to help diagnose your condition.

Urine Cytology

With urine cytology, a healthcare provider 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. That's why it's not a good screening test and used mostly in people who already have signs 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.

Procedural Tests

Now, let's take a look at the more conclusive, yet somewhat invasive, diagnostic tests.

Cystoscopy

Along with urine tests, a urologist will perform a cystoscopy, the gold standard test for diagnosing bladder cancer.

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 healthcare provider'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. If there is a tumor, they can see where exactly it is, what it looks like, how big it is, and whether there are any mucosal abnormalities.

During the cystoscopy, if a tumor or abnormal area of the bladder is seen, your urologist will take a biopsy of it. Then, a healthcare provider called a pathologist can look at the biopsy under a microscope and see if cancer cells are present.

Transurethral Resection of Bladder Tumor

If cancer cells are present, a procedure called a transurethral resection of bladder tumor, or TURBT, will be performed. This is performed in an operating room under general anesthesia and provides confirmation of a bladder cancer diagnosis. A TURBT entails the healthcare provider removing the bladder tumor as well as part of the muscular wall near the tumor.

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

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

Imaging Tests

Imaging tests are also needed to evaluate a bladder cancer diagnosis. 

CT or MRI Scans

A CT urogram is an imaging test used to evaluate the kidneys, 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 scans are unavailable.

• An intravenous pyelogram, or IVP, is a procedure in which a dye is injected into a person's vein and then an x-ray of the urinary tract system is taken.
• A CT scan of the chest is performed to determine if the cancer has spread to the lungs.
• A bone scan may be ordered if a person with bladder cancer has bone pain.

Staging

In addition to the grade of your tumor, your healthcare provider will also determine its stage, meaning 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 as well as in your chance of recovery.

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 healthcare provider 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 healthcare provider 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.