Bladder Cancer: Symptoms, Diagnosis & Treatment

What is bladder cancer?

Bladder cancer occurs when cells lining the bladder grow abnormally and form a tumor. About 90% of cases are urothelial carcinoma — also called transitional cell carcinoma — arising from the urothelium, the specialized lining of the bladder. Rarer types include squamous cell carcinoma, adenocarcinoma, and small cell carcinoma.

It usually develops after age 55, with an average age at diagnosis around 73. Incidence has been declining by about 1% per year, largely reflecting reduced smoking.

Is blood in the urine always bladder cancer?

No — most blood in the urine has a benign cause, including infection, stones, or an enlarged prostate. But painless visible blood in the urine is the classic presenting sign of bladder cancer and always requires evaluation, even a single episode that clears on its own.

This deserves emphasis because the natural history misleads people. Bladder cancer bleeding is typically:

• Painless — unlike the burning of an infection

• Intermittent — present for a day or two, then gone for weeks

• Variable — anywhere from faintly pink or tea-coloured urine to visible clots

The absence of pain and the disappearance of the blood are precisely what make men wait. If you have seen blood in your urine even once, that finding needs a workup regardless of whether it returned.

Blood detectable only on a urine test (microscopic hematuria) also warrants evaluation, though the approach is risk-stratified based on age, smoking history, sex, and the degree of blood present.

What are the symptoms of bladder cancer?

The most common sign — by a wide margin:

• Visible blood in the urine, usually painless and often intermittent

Other possible symptoms, generally later or less common:

• Urinary frequency and urgency

• Burning or pain with urination

• Difficulty urinating or a weak stream

• Feeling of incomplete emptying

• Pelvic or flank pain

• Recurrent urinary tract infections that don’t fully resolve

Symptoms suggesting advanced disease:

• Bone pain

• Unexplained weight loss or fatigue

• Swelling in the legs

• Inability to urinate

Note the overlap with urinary infection and enlarged prostate. Bladder cancer symptoms are not distinctive — which is why the blood, not the pattern, is the signal that matters. Male urinary symptoms →

What causes bladder cancer?

Smoking is by far the leading cause, responsible for roughly half of all cases. Carcinogens from tobacco are filtered by the kidneys and concentrated in urine, where they sit in prolonged contact with the bladder lining. Smokers have several times the risk of non-smokers. Risk falls after quitting, though it doesn’t return fully to baseline — which makes quitting worthwhile at any point, including after a diagnosis, since continued smoking raises the risk of recurrence.

Occupational chemical exposure is the second major cause, particularly aromatic amines. Higher-risk occupations include painters, metal workers, leather workers, rubber and plastics manufacturing, dye industry work, hairdressing, truck driving, mining, and firefighting. Exposures decades in the past still count — latency can exceed 20 years, so mention your full work history to your urologist.

Other established risk factors:

• Age — most cases occur after 55

• Sex — about three-quarters of cases are in men

• Race — more common in white people, though Black patients often present at later stages

• Chronic bladder irritation — long-term catheter use, recurrent infections, bladder stones

• Prior pelvic radiation — including radiation for prostate cancer

• Prior chemotherapy — particularly cyclophosphamide

• Arsenic in drinking water

• Family history and inherited conditions including Lynch syndrome

• Schistosomiasis — a parasitic infection linked to squamous cell bladder cancer, relevant for patients from endemic regions

How is bladder cancer diagnosed?

• Urinalysis and urine culture — confirms blood, rules out infection

• Urine cytology — examines urine for cancer cells; useful for high-grade disease, less sensitive for low-grade

• Urine tumour markers — increasingly used to help stratify risk in hematuria evaluation

• Cystoscopy — a thin lighted scope passed into the bladder. This is the definitive diagnostic test; no imaging reliably substitutes for looking directly. Usually done in the office under local anaesthetic

• Upper tract imaging — CT urogram or equivalent, to check the kidneys and ureters, since urothelial cancer can arise anywhere along that lining

• TURBT (transurethral resection of bladder tumour) — both diagnostic and therapeutic: the tumour is removed through the urethra and sent to pathology, establishing the grade and, crucially, whether the tumour has invaded the bladder muscle

• Staging scans — CT or MRI of chest, abdomen, and pelvis when muscle invasion is found

The distinction that determines everything: NMIBC vs. MIBC

Bladder cancer splits into two fundamentally different diseases, and the split is the most important thing to understand about your diagnosis.

Grade matters alongside stage. Low-grade tumours tend to recur but rarely progress. High-grade tumours, including carcinoma in situ (CIS), are far more likely to invade and are treated aggressively even when non-invasive.

How is bladder cancer treated?

Non-muscle-invasive bladder cancer

TURBT is the first step for essentially everyone — removing all visible tumour through the urethra with no external incision. For low-risk disease, a single dose of intravesical chemotherapy given shortly after surgery reduces recurrence. A repeat TURBT is often performed for high-grade or T1 tumours to confirm complete resection.

Intravesical BCG is the standard treatment for intermediate- and high-risk NMIBC. BCG is a live attenuated bacterium instilled directly into the bladder through a catheter, provoking a local immune response against the tumour. It is given as a weekly induction course followed by maintenance over months to years. It substantially reduces both recurrence and progression, and it is the reason many men keep their bladders.

Intravesical chemotherapy — gemcitabine, mitomycin, or gemcitabine/docetaxel in combination — is used for lower-risk disease, during BCG shortages, or when BCG isn’t tolerated.

For BCG-unresponsive disease, the options have expanded considerably in recent years and now include systemic pembrolizumab, nadofaragene firadenovec, nogapendekin alfa inbakicept, and an intravesical gemcitabine releasing system — several of which allow men to avoid or defer bladder removal. Ongoing trials continue to add to this list. If you have been told your only remaining option is cystectomy, a second opinion at a centre following these developments is reasonable.

Surveillance is lifelong and non-negotiable. Bladder cancer has among the highest recurrence rates of any cancer. Regular cystoscopy — initially every three months, spacing out over time if you remain clear — is a permanent part of life after diagnosis. This is the single biggest practical adjustment most patients make.

Muscle-invasive bladder cancer

Neoadjuvant chemotherapy comes first. For cisplatin-eligible patients, cisplatin-based chemotherapy given before surgery improves survival compared with surgery alone. This sequence matters, and it is a common point of confusion — the chemotherapy is not an afterthought following the operation.

Radical cystectomy removes the bladder and nearby lymph nodes, plus the prostate and seminal vesicles in men. It can be performed open or robotically. Urinary diversion is created at the same time, in one of three main forms:

• Ileal conduit — urine drains through a stoma into an external bag

• Neobladder — a new bladder constructed from bowel and connected to the urethra, allowing more normal urination

• Continent cutaneous reservoir — an internal pouch emptied with a catheter through a small stoma

The choice depends on tumour location, kidney function, dexterity, and your own priorities, and deserves an unhurried discussion.

Trimodal therapy — maximal TURBT followed by chemotherapy given alongside radiation — is a bladder-preserving alternative to cystectomy for carefully selected patients. In appropriate candidates, outcomes can be comparable. It is an alternative to surgery, not something added after it.

Perioperative immunotherapy has become part of standard practice for muscle-invasive disease, with checkpoint inhibitors added around chemotherapy and surgery improving outcomes.

Advanced and metastatic bladder cancer

This is where treatment has changed most dramatically.

Enfortumab vedotin plus pembrolizumab — an antibody-drug conjugate combined with immunotherapy — is now the first-line standard for advanced urothelial carcinoma, having demonstrated substantially better survival than platinum chemotherapy, regardless of PD-L1 status. Long-term follow-up continues to show durable benefit.

Other systemic options include platinum-based chemotherapy, avelumab maintenance after platinum response, and erdafitinib for tumours carrying FGFR2/3 alterations — which makes molecular testing of the tumour worthwhile.

Clinical trials are particularly worth asking about in bladder cancer. Several of the treatments now considered standard were trial-only within the past few years.

Bladder cancer survival rates

Survival depends heavily on stage at diagnosis, and the gap is wide:

These figures reflect patients diagnosed several years ago and do not capture the benefit of treatments approved since — a meaningful caveat in advanced disease, where the landscape has shifted substantially. They are also population averages that cannot predict an individual outcome.

The contrast between the top and bottom rows is the entire argument for not ignoring blood in your urine.

Why choose Dr. Samadi

• Board-certified urologist and fellowship-trained urologic oncologist

• Prompt hematuria evaluation — cystoscopy and upper tract imaging, without the delay that costs stage

• Second opinions welcome, including review of outside pathology, imaging, and prior treatment

• Midtown Manhattan office at 485 Madison Avenue, convenient to Grand Central

We accept most major insurance plans; our team will verify your coverage before your visit.

Schedule an evaluation

If you have seen blood in your urine — even once, even briefly — that finding deserves a prompt evaluation.

Request an Appointment

Office: 485 Madison Avenue, 21st Floor, New York, NY 10022 Phone: (212) 365-5000 Hours: [insert hours]

Sources

• American Cancer Society. Cancer Facts & Figures 2026; Key Statistics for Bladder Cancer; Survival Rates for Bladder Cancer.

• Siegel RL, et al. Cancer Statistics, 2026. CA: A Cancer Journal for Clinicians.

• Barocas DA, Lotan Y, Matulewicz R, et al. Updates to Microhematuria: AUA/SUFU Guideline (2025). Journal of Urology.

• American Urological Association / SUO. Non-Muscle-Invasive Bladder Cancer Guideline.

• Powles T, et al. Enfortumab Vedotin and Pembrolizumab in Untreated Advanced Urothelial Cancer (EV-302/KEYNOTE-A39). New England Journal of Medicine.

• NCI Surveillance, Epidemiology, and End Results (SEER) Program. Cancer Stat Facts: Bladder Cancer.

This page provides general medical information and is not a substitute for individualized medical advice. Discuss your diagnosis and treatment options with a qualified physician.