Tests for Bladder Cancer

Bladder cancer is often found because of signs or symptoms a person is having. Sometimes it might be found because of the results of a lab test a person gets for another reason.

If bladder cancer is suspected, exams and tests will be needed to confirm the diagnosis. If cancer is found, more tests will be done to help find out the extent (stage) of the cancer.

Medical history and physical exam

Your doctor will ask about your medical history to learn more about your symptoms. The doctor might also ask about possible risk factors for bladder cancer, including your family history.

A physical exam can provide information about possible signs of bladder cancer and other health problems. The doctor might do a digital rectal exam (DRE), during which a gloved, lubricated finger is put into your rectum. If you are a woman, the doctor might do a pelvic exam as well. During these exams, the doctor can sometimes feel a bladder tumor, determine its size, and feel if and how far it has spread.

If the results of the history and exam suggest bladder cancer might be the cause, the doctor will order lab tests to help find out for sure.

If you’re seeing your primary care doctor, you might also be referred to a urologist for further tests and treatment. A urologist is a doctor who specializes in diseases of the urinary system and male reproductive system.

Urine lab tests

Urinalysis

This is a simple lab test to check for blood and other substances in a sample of urine.

Urine cytology

For this test, a sample of urine is looked at with a microscope to see if there are any cancer or pre-cancer cells in it. Cytology is also done on any bladder washings taken during a cystoscopy (see below). Cytology can help find some cancers, but it isn't perfect. Not finding cancer on this test doesn’t always mean you are cancer free.

Urine culture

If you're having urinary symptoms, this test may be done to see if they’re from an infection. Urinary tract infections (UTIs) and bladder cancers can cause many of the same symptoms.

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. It can take time for the bacteria to grow, so it may take a few days to get the results of this test.

Urine tumor marker (biomarker) tests

Different urine tests can be used to look for specific substances made by bladder cancer cells (known as tumor markers or biomarkers). One or more of these tests may be used, often along with urine cytology, to help see if you have bladder cancer:

• UroVysion: This test looks for chromosome changes that are often seen in bladder cancer cells.
• BTA tests: These tests look for a substance called bladder tumor antigen (BTA), also known as CFHrp, in the urine.
• ImmunoCyt: This test looks at cells in the urine for the presence of substances such as mucin and carcinoembryonic antigen (CEA), which are often found on cancer cells.
• NMP22 BladderChek: This test looks for the NMP22 protein in the urine. People who have bladder cancer often have higher levels of this protein.

Other biomarker tests might be used as well, and many new biomarker tests are now being developed.

Some doctors find urine biomarker tests to be useful in looking for bladder cancers, but these tests may not always be helpful. Most doctors feel that cystoscopy is still the best way to find bladder cancer.

Some of these tests might be more helpful for looking for bladder cancer that has come back in someone who has already had it, rather than for first diagnosing it.

Cystoscopy

If bladder cancer is suspected, your doctor will likely recommend a cystoscopy, which is a procedure done by a urologist.

For this test, a cystoscope, which is a long, thin, flexible tube with a light and a lens or a small video camera on the end, is inserted through the urethra and up into the bladder. This lets the doctor look at the inner lining of the bladder, as well as take biopsy samples from abnormal areas, if needed (see “Biopsy results” below). For details on how this procedure is done, see Cystoscopy.

Fluorescence cystoscopy (also known as blue light cystoscopy) may be done along with routine cystoscopy. For this exam, a light-activated drug is put into the bladder during cystoscopy. This drug is taken up by cancer cells. When the doctor shines a blue light through the cystoscope, any cells containing the drug will glow (fluoresce). This can help the doctor see abnormal areas that might have been missed by the white light normally used.

Bladder cancer can sometimes start in more than one area of the bladder (or in other parts of the urinary tract). Because of this, the doctor may take samples from different parts of the bladder, especially if cancer is strongly suspected but no tumor can be seen. Salt-water washings of the inside the bladder may also be collected and tested for cancer cells.

Transurethral resection of bladder tumor (TURBT)

A cystoscopy can often be used to make the initial diagnosis of bladder cancer, but this typically needs to be confirmed with a transurethral resection of bladder tumor (TURBT), also known as just a transurethral resection (TUR).

During this procedure, the doctor removes any tumors from the bladder lining, as well as some of the bladder muscle around the tumors. The removed samples are then sent to a lab to look for cancer. If cancer is found, testing can also show if it has invaded (spread into) the muscle layer of the bladder wall. This is important in determining the stage (extent) of the cancer, which can help determine the best treatment options.

As with cystoscopy, the doctor might use a special light source to find tumors in the bladder:

• Fluorescence endoscopy is much like fluorescence cystoscopy, which is described above.
• For narrow band imaging (NBI), a special wavelength of light is used to help show tumors and nearby blood vessels in the bladder lining.

TURBT can also be thought of as part of the treatment for most early-stage bladder cancers (see Treatment of Bladder Cancer, by Stage).

For more on how this procedure is done, see Bladder Cancer Surgery.

Biopsy results

Biopsy samples (from a cystoscopy or TURBT) are sent to a lab, where they are looked at and tested by a pathologist, a doctor trained in diagnosing diseases such as cancer with lab tests. If bladder cancer is found, 2 important features are its invasiveness (part of the stage) and grade.

Invasiveness

The biopsy can show how deeply the cancer has grown into the bladder wall. This is very important in deciding treatment options.

Bladder cancers are often grouped based on if they have invaded into the main muscle layer of the bladder wall:

Non-muscle invasive bladder cancer (NMIBC) has not grown into the muscle layer. This is also sometimes described as superficial bladder cancer. Included in this group are:

• Non-invasive (stage 0) bladder tumors: These tumors have not grown deeper than the layer of cells they started in.
• Early invasive (stage I) bladder cancers: These tumors have grown into the layer of connective tissue under the lining layer of the bladder, but have not reached the muscle layer in the bladder wall.

Muscle invasive bladder cancer (MIBC) has grown into the muscle layer of the bladder wall, and possibly deeper. These cancers are more likely to spread, and they tend to be harder to treat.

For more on how bladder cancers might be described on a biopsy, see What Is Bladder Cancer?

Grade

Bladder cancers are also assigned a grade, based on how the cancer cells look under a microscope.

• Low-grade cancers (also called well-differentiated cancers) look more like normal bladder tissue. These cancers tend to grow slowly.
• High-grade cancers look less like normal tissue. These cancers may also be called poorly differentiated or undifferentiated. High-grade cancers are more likely to grow into the bladder wall and spread outside the bladder. In fact, most invasive bladder cancers are high grade. These cancers tend to be harder to treat.

Testing bladder cancer cells for gene or protein changes

If you have advanced bladder cancer, your cancer cells might be tested for certain gene or protein changes that could affect your treatment options. This type of testing might go by different names, such as molecular, genomic, or biomarker testing. It might be done on cells from a biopsy sample or from a sample of your blood.

For example, testing might be done to check the cancer cells for changes in the FGFR3 gene. Cancers with changes in this gene are more likely to be helped by treatment with a targeted drug. Tests might also be done to look for other gene or protein changes that could affect your treatment.

To learn more about this type of testing, see Biomarker Tests and Cancer Treatment.

Genetic testing for some people with bladder cancer

Not everyone with bladder cancer might need genetic testing. But some people might have an inherited gene change that greatly increased their risk of bladder cancer. This is more likely in people who:

• Are diagnosed with bladder cancer at a younger age (typically before age 45)
• Also have a family history of colon or bladder cancer (and therefore might have Lynch syndrome)

For many people with bladder cancer, genetic counseling and/or testing might be recommended to look for certain inherited gene changes. Before being tested, it’s important to understand what genetic testing might or might not tell you, as well as what the results might mean for you (and possibly your family members). This is why it’s important to speak with your doctor or a genetic counselor before being tested.

For more on genetic testing in general, see Understanding Genetic Testing for Cancer Risk.

Imaging tests

Imaging tests use x-rays, magnetic fields, sound waves, or radioactive substances to make pictures of the inside of your body.

If your doctor thinks you might have bladder cancer, one or more of these tests might be done to look for tumors in the bladder (or in other parts of the urinary tract), which can then be biopsied to find out for sure.

If you’ve been diagnosed with bladder cancer, your doctor may order some of these tests to see if the cancer has spread to tissues and organs near the bladder, to nearby lymph nodes, or to distant parts of your body.

If an imaging test shows enlarged lymph nodes or other possible signs of cancer spread, some type of biopsy might be needed to confirm the findings.

Computed tomography (CT) scan

A CT scan uses x-rays to make detailed cross-sectional pictures of your body. A CT scan of the kidney, ureters, and bladder is called a CT urogram. It can provide detailed information about the size, shape, and position of any tumors in the urinary tract, including the bladder. It can also help show enlarged lymph nodes that might contain cancer, as well as other organs in the abdomen (belly) and pelvis.

A CT scan of the chest might also be done to look for tumors in the lungs, especially for bladder cancers that are at higher risk of spreading.

CT-guided needle biopsy: CT scans can also be used to guide a biopsy needle into a suspected tumor. This is not done to biopsy tumors in the bladder, but it can be used to take samples from areas where the cancer may have spread, such as a lymph node. To do this, you lie on the CT scanning table while the doctor advances a biopsy needle through your skin and into the tumor.

Before having a CT scan, it’s important to tell your doctor if you have any allergies or have ever had a reaction to CT or x-ray dyes, or if you have any type of kidney problems, such as chronic kidney disease or an elevated creatinine blood test.

Magnetic resonance imaging (MRI)

Like CT scans, MRIs show detailed images of soft tissues in the body. But MRIs use radio waves and strong magnets instead of x-rays to make the images.

MRI images are very useful in showing cancer that has spread outside of the bladder into nearby tissues or lymph nodes. A special MRI of the kidneys, ureters, and bladder, known as an MRI urogram, might be used instead of a CT urogram to look at the upper part of the urinary system, especially in people with poor kidney function or who have had reactions to x-ray contrast dyes in the past.

Ultrasound

Ultrasound uses sound waves and their echoes to create pictures of internal organs. It can be useful in determining the size of a bladder cancer and whether it has spread beyond the bladder to nearby organs or tissues. It can also be used to look at the kidneys.

This is usually an easy test to have, and it uses no radiation.

Ultrasound-guided needle biopsy: Ultrasound can also be used to guide a biopsy needle into a suspected area of cancer in the abdomen or pelvis.

Intravenous pyelogram (IVP)

An intravenous pyelogram (IVP), also called an intravenous urogram (IVU), is an x-ray of the urinary system taken after injecting a special dye into a vein. This dye is removed from the bloodstream by the kidneys and then passes into the ureters and bladder. X-rays are done while this is happening. The dye outlines these organs on the x-rays and helps show urinary tract tumors.

This test isn’t done as much as it was in the past, as often a CT scan (see above) can be done to provide the same information.

Before having an IVP, it’s important to tell your doctor if you have any allergies or have ever had a reaction to CT scan or x-ray dyes, or if you have any type of kidney problems. If so, your doctor might choose to do another test instead.

Retrograde pyelogram

For this test, a catheter (thin tube) is put in through the urethra and up into the bladder or into a ureter. Then a dye is injected through the catheter to make the lining of the bladder, ureters, and kidneys easier to see on x-rays.

This test isn’t used often, but it may be done (along with ultrasound of the kidneys) to look for tumors in the urinary tract in people who can’t have an IVP.

Chest x-ray

A chest x-ray may be done to see if the bladder cancer has spread to the lungs. This test is not needed if a CT scan of the chest has been done.

Positron emission tomography (PET) scan

A PET scan is not commonly done in people with bladder cancer, but it might be used to see if the cancer has spread to lymph nodes or other parts of the body. It is more likely to be useful in people whose cancer is at higher risk for spreading.

For this test, you are injected with a slightly radioactive form of sugar (known as FDG), which collects mainly in cancer cells. A special camera is then used to create a picture of areas of radioactivity in the body. A PET scan doesn’t show as much detail as an MRI or CT scan, but it can often show cancer spread in any part of the body.

PET/CT scan: Many centers have special machines that do both a PET and CT scan at the same time (PET/CT scan). This lets the doctor compare areas of higher radioactivity on the PET scan with the more detailed appearance of that area on the CT scan.

Bone scan

A bone scan can help look for cancer that has spread to bones. This test usually isn't done unless you have symptoms such as bone pain, or if blood tests show the cancer might have spread to your bones. 

For this test, you get an injection of a small amount of low-level radioactive material that settles in areas of damaged bone throughout your body. A special camera detects the radioactivity and creates a picture of your skeleton.

A bone scan may suggest cancer in the bone, but to be sure, other imaging tests such as plain x-rays, MRI scans, or even a bone biopsy might be needed.

Biopsies to look for cancer spread

If imaging tests suggest the cancer might have spread outside of the bladder, a biopsy might be needed to be sure.

In some cases, biopsy samples of suspicious areas are taken during surgery to remove the bladder cancer.

Another way to get a biopsy sample is to use a long, thin, hollow needle to take a small piece of tissue from the abnormal area. This is known as a needle biopsy, and by using it the doctor can take samples without surgery. Sometimes a CT scan or ultrasound is used to help guide the biopsy needle into the abnormal area.