If there is a reason to suspect you might have bladder cancer, the doctor will use one or more methods to find out if this disease is really present. If it is, then the extent of spread (stage) of the disease will also be determined.
 

Signs and symptoms of bladder cancer

Blood in the urine

In most cases, blood in the urine (hematuria) is the first warning signal of bladder cancer. Sometimes, there is enough blood to change the color of the urine. Depending on the amount of blood, the urine may be very pale yellow-red or, less often, darker red. In other cases, the color of the urine is normal but small amounts of blood can be found by urine tests done because of other symptoms or as part of a general medical checkup.
 

Blood in the urine does not mean you have bladder cancer. Much more often it is caused by other things, such as infection, benign tumors, stones in the kidney or bladder, or other benign kidney diseases. Blood may be present one day and absent the next, with the urine remaining clear for weeks or months. With bladder cancer, blood eventually reappears. Usually, the early stages of bladder cancer cause bleeding but little or no pain.
 

Change in bladder habits or irritative symptoms

Having to urinate more often than usual can also be a symptom of bladder cancer. Irritative symptoms, such as dysuria (burning during urination) and urgency (feeling as if you need to go but not being able to) can also be symptoms of bladder cancer. However, these symptoms are also more likely to be caused by a benign condition such as infection, benign tumors, bladder stones, an overactive bladder, or an enlarged prostate.
 

Medical history and physical exam

The first step is for your doctor to take a complete medical history to check for risk factors and symptoms. A physical exam provides other information about signs of bladder cancer and other health problems. The doctor might examine the rectum and vagina (in women) to determine the size of a bladder tumor and to see if and how far it has spread.
 

Cystoscopy

If bladder cancer is suspected, doctors will recommend a cystoscopy. For this procedure, a slender tube with a lens and a light (a cystoscope) is placed into the bladder through the urethra. This allows the doctor to look inside the bladder. Cystoscopy can be done in the office or in the operating room. This procedure is performed by a urologist, a specialist in diseases of the urinary system. Usually the first cystoscopy will be done in the doctor's office using a small flexible fiberoptic device. Some sort of local anesthesia may be used to numb the bladder for the procedure. If a general or spinal anesthesia is used, the procedure is done in the operating room. If an area looks abnormal or a growth is seen, it will be biopsied (a small piece of tissue from the area is removed to be examined under the microscope). During cystoscopy, bladder washings may be done for to look for cancer cells. Washings are taken by placing a salt solution into the bladder (through a tube) and then removing the solution for microscopic testing.
 

Fluorescence cystoscopy may be done along with routine cystoscopy. For this procedure, substances called porphyrins are put into the bladder during cystoscopy. These substances are taken up by cancer cells. Then, when the doctor shines a blue light through the cystoscope, the cells containing the porphyrins will glow (fluoresce). This can allow the doctor to see areas with cancer cells that may have been missed by the white light normally used.
 

Lab tests

Urine cytology

The urine is examined under a microscope to see if it contains any cancer or pre-cancer cells. Cytology is also done on any bladder washings taken when the cystoscopy was done. Although cytology can help find some cancers, this test is not perfect. Not finding cancer on this test doesn’t always mean you are cancer free.
 

Urine culture

For a urine culture, a sample of urine is put into a dish in the lab to allow any bacteria that are present to grow. Because it can take time for the bacteria to grow, it may take a few days to get the results of this test. This test is done to make sure that the urine is not infected. Infections and bladder cancers can cause similar symptoms.
 

Biopsy

When a piece of tissue from an abnormal area is removed to see if it contains cancer cells, the procedure is called a biopsy. The tissue that is removed is sent to the lab so that a pathologist can look at it under the microscope. A pathologist is a doctor who specializes in diagnosing diseases by examining tissues with a microscope.
 

Bladder biopsies: Bladder biopsy samples are most often obtained during cystoscopy. This allows the doctor to be precise in terms what tissue is removed. A biopsy can show if cancer is present and what type of cancer it is (transitional cell carcinoma, squamous cell carcinoma, adenocarcinoma, etc.). It can also show how deeply the cancer has penetrated into the bladder wall, which is very important in deciding treatment.
 

Bladder cancers are graded based on how they look under the microscope.

• Low-grade cancers look more like normal bladder tissue. They are also called well-differentiated cancers. These cancers usually have a good prognosis (outlook).

• High-grade cancers look less like normal tissue. These cancers may be called either poorly differentiated or undifferentiated. High-grade cancers are more likely to grow into the bladder wall and to spread outside the bladder. These cancers tend to have a less favorable prognosis.

It is not unusual for people with one bladder cancer to develop more cancers in other areas of the bladder or in the urinary system. For this reason, the doctor may take tissue samples from several different areas of the bladder lining.
 

Needle biopsies: Although images from tests (see the next section) can suggest the cancer has spread, a biopsy is the only way to be sure. In some cases, these samples are obtained during the surgery to remove the bladder cancer. Another way to get a biopsy sample is to use a needle to take tissue from the abnormal area. This is known as a needle biopsy, and it can allow the doctor to take samples without an operation. Needle biopsies are sometimes done using a CT scan or ultrasound to accurately guide the biopsy needle into the abnormal area.