What Is Urothelial Bladder Cancer?

The urinary tract is made up of multiple organs that help the body filter waste products from the blood. The kidneys filter the blood and develop urine, which then moves through tubes called ureters into the bladder.

The bladder is a pouch that holds the urine until it is ready to leave the body. The urine then moves from the bladder into the urethra, which is an opening that allows the urine to pass out of the body.

The bladder is lined with a layer of cells called urothelial cells. Beneath these urothelial cells are deeper layers of the bladder, ending with the muscle layer.

When cancer cells develop in the bladder, they usually occur in this urothelial layer. About 90% of all bladder cancers start here. This layer is frequently exposed to the chemicals in the urine, which over time can be damaging to these cells.

Bladder cancer is most often diagnosed in older people, with an average age of 73 at diagnosis. Males are more likely to have bladder cancer than females. It is the fourth most common cancer in men.

This article will review the symptoms, causes, and treatment for urothelial bladder cancer. 

Symptoms

One of the first symptoms and the most common symptom is blood in the urine. This is called hematuria. There may be enough blood to be seen after urinating, or it may be in smaller amounts that can’t be seen easily. A urinalysis can detect microscopic amounts of blood. The blood may also occur on occasion and not be present every day.

Other symptoms of bladder cancer can include:

• Urinating more frequently than normal
• Burning or discomfort when urinating
• Urinating often during the night
• Having a weak urine stream
• Feeling of being unable to pass urine
• Pain in the lower back or abdomen

Causes

There is no single factor that causes bladder cancer to develop. Urothelial bladder cancer develops when the genetic material (DNA) inside of the urothelial cells lining the bladder becomes abnormal. These abnormal cells then divide and produce more abnormal cells. As more abnormal cells are made, the tumor develops.

Though there is not one specific cause for urothelial bladder cancer, there are several risk factors that may make bladder cancer more likely to occur. These risk factors include:

• Smoking
• Chemical exposures in the workplace, such as in the following occupations:  painters, leatherworkers, and dye, rubber-tire, aluminum, steel, and iron industry workers
• Previous treatment with the chemotherapy medications cyclophosphamide or ifosfamide
• Use of the herb aristolochic acid (found in some herbal supplement used for arthritis and gout)
• Arsenic exposure
• Chronic bladder infections
• Previous radiation treatment to the pelvis

It is also possible that someone can be born with a gene that makes them more likely to develop bladder cancer. Some of the genes that may increase the risk include PTEN and RB1. 

Diagnosis

When a bladder cancer diagnosis is suspected, many tests can be performed to help determine the cause of the symptoms and make the diagnosis.

History and Physical Exam

Obtaining a medical history can be very important. During this discussion, the patient will notify the doctors of any previous illnesses or medical conditions they have had and can learn about their risk factors for bladder cancer. 

During a physical examination, the abdomen may be gently pressed on to see if any masses can be felt. For females, a pelvic exam may be done to evaluate the uterus and ovaries. For males, a digital rectal exam may be performed to evaluate the prostate.

Urine Tests

There are multiple lab tests that can be performed from a single urine sample. A urinalysis looks for the presence of blood in the urine. A urine culture checks for the growth of bacteria in the urine. A urine cytology determines if there are cancer cells in the urine.

Imaging Tests

A cystoscopy is one of the most frequently ordered imaging tests. During a cystoscopy, the doctor places a thin camera into the urethra (the outer opening where urine leaves the body) and up toward the bladder. This allows the doctor to inspect the bladder walls and see if any tumors or other abnormalities are present.

A cystoscopy is the best way to view the inside of the bladder, but other tests such as a CT (computed tomography) scan may be ordered to look at the areas around the bladder to see if any abnormal findings are present.

Biopsy

If a suspicious area is found during cystoscopy, a biopsy will be done. During a biopsy, a sample of the abnormal tissue is removed and evaluated in a lab to determine if cancer cells are present. The biopsy procedure is called a TURBT (transurethral resection of bladder tumor). A TURBT is performed much in the same way as a cystoscopy, but during a TURBT, a portion of the tumor along with the bladder wall is removed.

Cancer Staging

Once a bladder cancer diagnosis is made, the oncologist (a medical doctor specializing in diagnosing and treating cancer) will determine the stage of the cancer. This can help determine what treatment is needed as well as the prognosis.

Stages include:

Stage 0: In this stage, cancer is present but is very small in size and has not grown into the deeper layers of the bladder or spread to any lymph nodes. 

Stage 1: In this stage, cancer has grown a little deeper than the first layer of the bladder, but it has not grown into the muscle or to any lymph nodes. 

Stage 2: The cancer has spread into deeper layers of the bladder but has not gone through the muscle layer or spread into any lymph nodes or other areas of the body. 

Stage 3a: The cancer has spread through the muscle layer into the fat surrounding the bladder, or has spread into one lymph node in the pelvis. It could also have spread into nearby areas such as the prostate or uterus but hasn’t spread to distant areas in the body. 

Stage 3b: The cancer has spread to more than one lymph node in the pelvis.

Stage 4: The cancer has grown through the bladder and into the abdominal wall or has spread to distant areas of the body, such as the bones or lungs. 

Treatment

Treatment for urothelial bladder cancer is dependent upon the stage of the cancer. Multiple treatments may be given in combination to best treat the cancer. 

Intravesical Therapy

This treatment can be used in early stages of bladder cancer that have not spread deep into the bladder wall. During this type of treatment, the cancerous tissue is removed during a TURBT, and then chemotherapy or immunotherapy is administered directly into the bladder to treat the area. Sometimes this process is only required once, but it may need to be repeated if cancer returns.

Surgery

Partial or full removal of the bladder may need to be done to treat the cancer. If full bladder removal is required, a patient will no longer be able to urinate normally, as there is no longer a pouch to hold the urine. A urostomy will be placed, which connects a small piece of intestine to an opening on the outside of the body called a stoma. This allows the urine to flow through to a bag attached to the outside of the body.

Chemotherapy

If bladder cancer has spread through the bladder muscle or into other areas of the body, chemotherapy may be needed. Chemotherapy is medication, usually given through an infusion or taken as a pill, that works by stopping cells from dividing, thereby destroying them.

Immunotherapy

Immunotherapy infusions may be given when cancer has spread to other areas of the body. This medication works differently than chemotherapy. Immunotherapy helps your body’s immune system detect, attack, and destroy the cancer.

Radiation Therapy

During radiation therapy, high energy X-ray beams are directed at the area being treated. This type of treatment may be used to treat small areas of tumor, or to treat larger areas and try to prevent surgical removal of the bladder. If bladder cancer has spread to other areas of the body and are causing symptoms, such as pain, radiation therapy may be needed to improve those symptoms.

Prognosis

The prognosis of urothelial bladder cancer varies based on how advanced the cancer has grown, as well as the size of the tumor, and if it is a new tumor or has regrown.

The five-year survival rate—the percentage of people still alive at five years after diagnosis—for bladder cancer that has not gone into deeper layers is 96%. 

If a tumor has invaded deeper layers but not the muscle wall, five-year survival is 69%. If it has spread into nearby lymph nodes or organs, the five-year survival rate is 37%. If bladder cancer has spread to distant areas of the body, five-year survival is 6%.

Coping 

A bladder cancer diagnosis may cause stress and worry. Side effects from the cancer or the treatments may cause distressing changes to the body. Finding ways to cope with these changes—through support groups or with family and friends—may be helpful. Discussing expectations and concerns with your healthcare team may be helpful as well.

A Word From Verywell

If you’re experiencing symptoms, especially blood in the urine, or if you are concerned that you may have bladder cancer, don’t hesitate to reach out to your healthcare team to discuss your concerns.

It is very possible that the symptoms you’re having may be due to other reasons, such as a urinary tract infection. But if caught early, bladder cancer has a much better prognosis, so it's important to catch it and begin treatment as soon as possible. Be sure to discuss any concerns you have about your urinary health with your healthcare team.