What is bladder cancer?

Most bladder cancers develop from the cells of the lining of the urinary tract, known as the urothelium. Tumours differ in their grade of malignancy and the depth to which they invade the bladder wall. This distinction is crucial for treatment.

This classification cannot be established reliably on the basis of ultrasound alone or solely from the appearance of the lesion during cystoscopy. Tissue is required for histopathological examination, including tissue that makes it possible to assess the depth of invasion.

Blood in the urine — the most important symptom that must not be ignored

Haematuria may turn the urine pink, red or brown. It may occur only once, disappear and then return after weeks or months. The absence of pain is not reassuring — bladder cancer often causes painless bleeding.

Blood that is not visible to the naked eye may be detected during urine testing. A positive dipstick result should be confirmed by microscopic examination because other factors may also alter the colour of the urine or the test reaction.

Haematuria has many possible causes, including infection, stones, kidney disease, injury, prostate enlargement, intense physical exercise or medicines. This is precisely why it requires diagnostic evaluation — not because it always means cancer.

“A single episode of painless haematuria is easy to dismiss because it disappears. In bladder diagnostics, however, we ask not only whether blood is present today, but whether it has appeared even once and whether its true cause is known.”

Other possible symptoms of bladder cancer

• more frequent urination;
• a sudden and difficult-to-control urge to urinate;
• burning or pain during urination;
• pain in the lower abdomen or pelvis;
• recurrent symptoms resembling infection despite negative cultures or no lasting improvement after treatment;
• in more advanced disease: pain in the lumbar region, weakness, weight loss or swelling of the limbs.

Irritative urinary symptoms are much more commonly caused by less serious conditions. However, they cannot by themselves distinguish between infection, urinary stones, overactive bladder and cancer. Persistent or recurrent symptoms without a confirmed infection require particular attention.

When is urgent help required?

Visible blood in the urine without systemic symptoms also requires prompt contact with a physician, but it does not always mean that an ambulance is necessary. The degree of urgency depends on the severity of the bleeding, the ability to pass urine and the patient’s general condition.

Who is at greater risk of bladder cancer?

The absence of risk factors does not rule out cancer, and their presence does not mean that the patient has the disease. They help the physician determine the scope and urgency of the haematuria work-up.

What does diagnosis involve, step by step?

1. Medical history: appearance and duration of haematuria, pain, symptoms of infection, smoking, occupation, anticoagulant medication, previous cancers and treatment.
2. Physical examination: the scope depends on the symptoms and the patient’s general condition.
3. Urine and blood tests: these may include urinalysis, microscopy, culture if infection is suspected, a full blood count and assessment of kidney function.
4. Imaging of the urinary tract: ultrasound, computed tomography using an appropriate protocol or another examination selected according to risk and kidney function.
5. Cystoscopy: direct inspection of the urethra and the inside of the bladder.
6. Histopathology: confirmation of the nature of the lesion and assessment of the depth of invasion in the removed tissue.

Not every patient requires the same set of tests. A single episode of haematuria in a young person with a confirmed infection is assessed differently from painless haematuria in a long-term smoker. The decision should be based on the complete clinical picture.

Cystoscopy — why is it so important?

Cystoscopy involves inserting a thin endoscope with a camera through the urethra. The physician examines the urethra, the ureteric orifices and the bladder mucosa in real time. Flexible cystoscopy is often used in an outpatient diagnostic setting.

The examination may reveal:

• a papillary tumour or a flat lesion;
• the source of bleeding;
• a stone, foreign body or inflammatory lesion;
• urethral narrowing or another abnormality;
• recurrence during follow-up after previous treatment.

Detailed information about the procedure, preparation and organisational arrangements is available on a separate page: flexible cystoscopy.

Does a normal ultrasound rule out a bladder tumour?

No. Ultrasound is a valuable, non-invasive examination and can detect some tumours, stones, urinary obstruction and other abnormalities. However, its sensitivity depends on factors including the size and location of the lesion, bladder filling, the patient’s body habitus and the quality of the examination.

Small, flat or unfavourably located lesions may not be clearly visible. Therefore, when appropriate indications are present, a normal ultrasound result does not replace cystoscopy. Conversely, cystoscopy does not assess the entire renal parenchyma and ureters, so it does not replace imaging of the upper urinary tract.

These tests complement one another rather than compete with each other.

Urine cytology and urine-based tests — can they replace cystoscopy?

Urine cytology evaluates cells shed into the urine. It is particularly helpful in detecting high-grade lesions and carcinoma in situ, but it has lower sensitivity for some low-risk tumours.

A negative result does not rule out cancer. An abnormal result must be interpreted in the context of cystoscopy and imaging. Available urinary markers may be useful in selected situations, but they do not routinely replace cystoscopy in the initial investigation of a suspected bladder tumour.

Does a urinary tract infection rule out cancer?

No. Infection is a common cause of burning, frequent urination and blood in the urine, but it may also coexist with another disease. If a urine culture confirms infection, the physician initiates treatment and determines whether and when the tests should be repeated.

Further evaluation is particularly required in the case of:

• haematuria persisting after the infection has been treated;
• recurrent visible blood in the urine;
• symptoms of “cystitis” with negative cultures;
• lack of improvement despite appropriately selected treatment;
• the presence of significant risk factors.

Repeating antibiotics without confirmation of infection may delay the correct diagnosis.

What does a suspicious lesion on cystoscopy mean?

If the physician sees a lesion suspicious for cancer, the next step is to plan its sampling or removal for histopathological examination. Transurethral resection of a bladder tumour is most commonly performed.

The pathologist assesses, among other features:

• whether the lesion is cancer and what type it is;
• the grade of the cancer cells;
• the depth of invasion into the bladder wall;
• whether the specimen contains muscle tissue that permits a reliable assessment;
• other features influencing the risk group and further treatment.

Further management can be planned only after combining the histopathological findings, the cystoscopic appearance and, where required, imaging results. This may include endoscopic surveillance, intravesical treatment, repeat resection or more advanced treatment.

What should you not do after noticing blood in the urine?

• do not wait until the bleeding has occurred several times;
• do not assume that anticoagulants are the cause — they may increase bleeding but do not automatically explain its source;
• do not treat yourself with antibiotics left over from a previous infection;
• do not regard a normal ultrasound as a complete exclusion of bladder disease;
• do not stop anticoagulant medication on your own before a consultation or cystoscopy;
• do not wait for pain — cancer-related haematuria may be painless.

Frequently asked questions about bladder cancer and cystoscopy