Bladder Cancer – Causes, Symptoms, Diagnosis, and Treatment Options

The bladder is a muscular organ lined with a mucous membrane on the inside. In most cases, a bladder tumor develops from this mucous membrane and goes unnoticed for a long time. Men are affected significantly more often than women, making bladder cancer one of the more common cancers among men.

Typical symptoms related to urination in older adults can be a sign, but the diagnosis of bladder cancer is often made only through incidental findings. About 75 percent of those affected have early-stage bladder cancer at the time of initial diagnosis, when the tumor is still confined to the mucous membrane—in these cases, the chances of successful treatment are particularly high.

In about 25 percent of cases, however, the bladder cancer is already advanced, meaning the tumor has penetrated the muscle layer of the bladder and has partially invaded neighboring organs such as the prostate or the uterus. These stages of bladder cancer usually require more intensive treatment.

The exact causes of bladder cancer are not yet fully understood. However, several risk factors for bladder cancer are known to significantly increase the risk of developing the disease. The primary risk factor is smoking, including secondhand smoke: experts estimate that 30 to 70 percent of all bladder tumors are attributable to this.

Other risk factors include occupational hazards—in particular

• repeated exposure to hazardous substances such as organic solvents, which is why bladder cancer is sometimes recognized as an occupational disease
• chronic inflammation, such as bladder infections
• infections caused by certain pathogens or sexually transmitted diseases (e.g., schistosomiasis or gonococci (-> the causative agent of gonorrhea)) that promote the development of the disease
• medications such as cyclophosphamide, which is used in cancer treatment

can increase the risk of bladder cancer.

Bladder Cancer as an Occupational Disease: Frequent Exposure to Hazardous Substances

According to analyses, the highest occupational risk for bladder cancer affects certain occupational groups. Those particularly at risk are

• metalworkers
• military personnel
• Cleaning staff
• Painters
• Hairdressers 
• Rubber industry workers.

These individuals face a significantly increased risk of bladder cancer due to exposure to aromatic amines and polycyclic aromatic hydrocarbons. These substances are found, among other places, in petroleum, fuels, soot, tar, tobacco smoke, dyes, rubber products, solvents, and plasticizers.

Other occupational groups—such as 

• brewery workers
• electricians
• firefighters
• healthcare workers
• blast furnace workers
• Waiters

may be affected. In such cases, bladder cancer is recognized as an occupational disease, as the link between exposure and the disease is well established medically. For patients with bladder cancer who were at occupational risk, this also plays a role in the assessment of pension and insurance benefits.

Bladder cancer is barely noticeable in its early stages and is therefore difficult to detect. One of the first signs of bladder cancer is hematuria—the presence of blood in the urine. This warning sign should always be taken seriously, as it may indicate bladder cancer and requires a medical examination without delay.

However, blood in the urine can also occur with other conditions, such as kidney stones, cystitis, or severe urinary tract infections. Therefore, it is important to have the cause medically evaluated in order to detect bladder cancer early.

Other typical symptoms of bladder cancer include:

• painless hematuria (blood in the urine)
• frequent urge to urinate
• Discomfort during urination
• a feeling of pressure on the bladder

Pain usually does not occur until bladder cancer has reached an advanced stage, when the tumor has already invaded deep into the muscle layer.

A suspected diagnosis of bladder cancer comes as a shock to most people, but it must always be confirmed or ruled out through specific diagnostic testing. Since there is currently no reliable rapid urine or blood test, cystoscopy is considered the gold standard.

The urologist first takes a medical history to identify risk factors such as smoking or occupational hazards, and examines the kidney and bladder regions. Urine test strips can detect hidden blood in the urine—an important indicator of possible bladder cancer. Abnormal blood test results or specific tumor markers in the urine (e.g., NMP 22, BTA stat, or ImmunoCyt) can also provide clues, but they are not sufficient on their own.

The most important test remains cystoscopy, which is generally painless. During the procedure, a thin endoscope is inserted through the urethra into the bladder, allowing the specialist to directly examine the mucous membrane and identify any potential tumor sites. To confirm the diagnosis, a biopsy is often performed: During this procedure, the doctor removes a tissue sample, which is then examined in the laboratory. This allows the tumor type to be determined and the stage of bladder cancer to be established—an important basis for planning the best possible individualized treatment for bladder cancer.

Image of the bladder lining from a cystoscopy © Courtesy of Dr. Robert Hefty, Urology, Heidenheim Clinics.

In cases of advanced bladder cancer, where the tumor has already invaded the muscle layer, surgery is usually performed promptly. During this procedure, the bladder is completely removed at a specialized clinic—this procedure is known as a radical cystectomy.

Follow-up care plays a crucial role afterward. Imaging techniques such as X-rays or computed tomography (CT) are used to check whether metastases have formed. These occur particularly frequently in the lymph nodes, liver, lungs, or bones and significantly worsen the prognosis for bladder cancer.

Treatment Options in the Early Stages

The treatment of bladder cancer depends heavily on the type of tumor, its stage, and its exact location. Medically, a distinction is made between superficial bladder cancer and invasive bladder cancer.

If the tumor is small and locally confined, it is usually removed using a minimally invasive procedure called a cystoscopy. The procedure is painless and performed under local anesthesia. Depending on whether the margins are tumor-free, a second procedure may be necessary.

In many cases, this is followed by chemotherapy for bladder cancer, which is administered locally directly into the bladder. As a result, side effects are usually minimal. In addition, immunotherapy for bladder cancer using BCG (a tuberculin preparation) can help prevent the disease from recurring.

Since the risk of recurrence is high with bladder cancer, regular follow-up examinations are crucial. Especially in the first few months after treatment, checkups are scheduled approximately every three months.

Treatments for Advanced-Stage Cancer

In cases of advanced bladder cancer that has already invaded the muscle layer, the treatment regimen is significantly different. In these cases, extensive surgery is performed to remove the entire bladder as well as the adjacent lymph nodes. These are considered prime sites for early lymph node metastases.

Possible consequences for both men and women include sexual dysfunction and urinary incontinence. This is usually followed by systemic chemotherapy for bladder cancer, which, however, can be associated with significant side effects.

In recent years, systemic immunotherapy for bladder cancer using modern checkpoint inhibitors such as pembrolizumab or nivolumab has also proven effective. These drugs help the immune system specifically target the tumor.

To improve quality of life, some patients undergo surgery to create a neobladder from small intestine tissue. Alternatively, an artificial urinary outlet (ileal conduit) with a collection bag can be created to partially restore continence.

Antibody-Drug Conjugates for Bladder Cancer

As of 2022, an antibody-drug conjugate has become available for the first time for the treatment of bladder cancer. It is used in particular for metastatic bladder cancer when prior chemotherapy or immunotherapy has not been sufficiently effective or is not possible due to severe side effects from bladder cancer treatment. This targeted therapy combines the action of antibodies with a chemotherapeutic agent, thereby enabling the targeted destruction of tumor cells.

Psychological Counseling and Therapy 

In addition to medical treatment, emotional support is also of great importance. Many patients with bladder cancer benefit from accompanying psychological support, such as that offered in psycho-oncology. There, not only those affected by bladder cancer but also their family members receive professional help in coping with the diagnosis and its consequences.

Bladder cancer support groups also provide an opportunity to connect with others facing similar challenges. Many specialized clinics and oncology centers offer such programs, which provide valuable support to patients and their families.

The earlier the tumor is detected and the lower the stage, the better the chances of recovery from bladder cancer. Nevertheless, bladder cancer often recurs after just a few years.

Such a recurrence of bladder cancer or the formation of metastases in lymph nodes, organs, or the skeleton significantly worsens the prognosis for bladder cancer. Therefore, regular follow-up examinations are crucial for detecting relapses early and treating them in a timely manner.

1. What are the initial symptoms that may indicate bladder cancer?
One of the most common signs of bladder cancer is blood in the urine (hematuria), often without pain. An increased urge to urinate, discomfort during urination, or a feeling of pressure in the bladder may also occur. Since these symptoms can have other causes, a medical evaluation is important for the early detection of bladder cancer.

2. How is bladder cancer diagnosed?
The most important step in diagnosing bladder cancer is a cystoscopy. During this procedure, the urologist can directly examine the bladder lining and, if necessary, take a tissue sample (biopsy). In addition, urine tests, blood tests, and imaging procedures such as CT or MRI are used to determine the stage of bladder cancer.

3. What treatment options are available for bladder cancer?
Treatment for bladder cancer depends on the type and stage of the tumor. In the early stages, the tumor is often removed using minimally invasive techniques, usually in combination with local chemotherapy or immunotherapy. In cases of advanced bladder cancer, a radical cystectomy (removal of the bladder) may be necessary. Systemic chemotherapy and immunotherapy, as well as new approaches such as antibody-drug conjugates, are also used.

4. What is the prognosis for bladder cancer?
The chances of a cure for bladder cancer are best when the tumor is detected early and has not yet invaded the muscle layer. However, recurrences are common in bladder cancer, which is why regular follow-up examinations are very important. If metastases develop in the lymph nodes, liver, lungs, or bones, the prognosis for bladder cancer worsens significantly.