Let's Talk About Bladder Cancer Signs and Symptoms
Everything you need to know to identify the signs of bladder cancer, including how to recognize different stages of the disease.
Sometimes you have no clue there's a problem with your bladder until your doctor wants you to go to a specialist. But if you have a sense that something’s not right, the symptoms here could be indications it's time to get things checked out. While there’s no screening test for bladder cancer, it does have one distinct (and scary) symptom, and that’s blood in the urine. There are other signs as well, and if you are over 55, it’s worth knowing them. Just remember, not all blood in the urine is bladder cancer, but if you see it and have some of these other common symptoms, it’s time to call an M.D.
Our Pro Panel
We went to some of the nation's top experts in bladder cancer to bring you the most up-to-date information possible.
Hooman Djaladat, M.D.
Urologic Oncologist and Associate Professor of Clinical Urology
University of Southern California Institute of Urology
Philippe Spiess, M.D.
Genitourinary Oncologist and Assistant Chief of Surgical Services
Moffitt Cancer Center
Gary Steinberg, M.D.
Urologic Oncologist and Bladder Cancer Surgeon
NYU Perlmutter Cancer Center
New York City
Even a little blood can turn your urine red, but other colors can include pink, rust, or even orange. Sometimes the blood comes out with clots (like a period). If it comes and goes and you still should get it checked out, just for your peace of mind.
Yes, if you have blood in your urine and the doctor has ruled out a UTI or other type of infection. Many people are scared to get one—it’s not fun to get probe up your urethra, but it doesn’t last more than ten minutes and you don’t feel much because you’ve been numbed and given sedatives. But that test combined with a scan or ultrasound can rule out benign tumors from malignant ones.
Not necessarily, especially if you don’t have other symptoms. You could just have an overactive bladder, which can be caused by a number of conditions, including diabetes, drinking too much caffeinated drinks or alcohol, an enlarged prostate or a UTI. But if your nighttime pee has blood, call the doctor.
While this could be a sign of bladder cancer, it's actually pretty rare. And when it does occur, it's usually not the only sign. Most of the time, people also have blood in the urine. The more likely explanation? You're dealing with an actual backache, not cancer.
What Is Bladder Cancer Again?
It’s the sixth most common type of cancer in the U.S. and happens when cells mutate and form tumors in the bladder, the hollow organ that stores urine. Most cases of bladder cancer are caught when the tumors are still in the first, or inner, lining of the bladder. But if they’re not removed or they return after treatment, they can spread into the other three layers, including the muscle and fatty tissues. That’s when you might need a major operation to remove your bladder and give you a fighting chance for recovery. And by the way, that chance for recovery is good. The average five-year survival rate is 77%; when it’s caught at its earliest stage, the number jumps to 96%.
What Are the Signs and Symptoms of Bladder Cancer?
Roughly 90% of people diagnosed with bladder cancer are over 55—and two-thirds of those cases occur in people ages 65 to 84. So Boomers, be aware of the symptoms below (especially if you’re a guy).
But even younger folks over 35 and who smoke or have other risk factors should know them too, according to the American Urological Association. Having any of them doesn’t necessarily mean you have bladder cancer.
However, if you have the number one sign—blood in the urine that you can see—along with some of these other symptoms, do yourself a favor and get checked out by a specialist. Bladder cancer, like any other type, is easier to treat when it’s caught early.
Here are the top four signs and symptoms of bladder cancer to watch out for.
1. Blood in the urine.
This is the first sign for 90% of bladder cancer patients—you pee and you see blood. Doctors call it gross hematuria. Normally, your first trip to the bathroom in the morning might produce a dark yellow pee, but after that it should be straw-colored (if you’re drinking enough liquids, that is).
Since kidneys always filter out blood cells from the waste, red blood cells shouldn’t be there. But tumors are filled with blood vessels that can burst easily. Pink, bright red, or rust-colored urine is an early warning signal even though there may be less alarming causes besides bladder cancer.
Some of these include kidney stones; a bladder or urinary tract infection; or an enlarged or infected prostate. But let a medical pro rule those out, not you. This is especially true if you have any of the risk factors for bladder cancer:
you smoke or are a former smoker
you live with someone who smokes
you have a job where you’re exposed to chemicals (like construction or firefighting)
you’re 55 or older
In a study of nearly 1,200 people who had blood in their urine, urologists at Weill Cornell Medical College in New York City found that 31%of them who had gross hematuria had bladder cancer. But that number skyrocketed to 64% for those people who were older than 65 and current or former smokers.
What about blood you can’t see? A microscope can pick up red blood cells in a urine sample, which your primary doctor might order during a yearly checkup. Anything over four red blood cells—yep, four—is considered abnormal. While this type of blood (known as microscopic hematuria) may seem less cause for concern, it can also be a sign of bladder cancer, though the risk hovers around 2% to 3%. Still, those numbers tick up if you have other risk factors, like your age or a history of smoking—up to 17% for a 60-year-old man who smokes, researchers at Weill Cornell Medical College discovered.
Bottom line: Blood is blood, which is why doctors urge you to get it checked out.
2. You’re going to the bathroom more often and/or you get sudden strong urges to go.
By themselves, changes in the ways you pee can be signs of anything—your age, an enlarged prostate, a UTI. But when you have those symptoms combined with blood in your urine that could signal something more serious.
There’s one exception: Carcinoma in situ (CIS), a type of aggressive pre-cancer. It can irritate the bladder so much it produces these symptoms—frequency and urgency—on its own. Again, you probably don’t have CIS—only 10% of bladder cancer patients do—but trust us, it’s better to know that sooner rather than later.
And if turns out aging bladder muscles are the only reason for these symptoms, a urologist can recommend exercises or medications for controlling your overactive bladder.
3. It hurts or burns when you pee, or you have trouble going, even when you have the urge.
Again, these can be symptoms of a UTI or an enlarged prostate when they appear alone. But if you also have blood in your urine, they could be signs of malignant tumors. Tumors located near the bladder’s opening and tumors that have spread to the urethra could be stopping the flow, or reducing the stream to a weak dribble.
4. Your lower back aches, usually on one side.
This sign is less common, but sharp pain in the back or a sharp pain that turns into a dull ache can also be traced to bladder cancer, especially if the tumor has gotten big enough to block the kidneys or spread to one of the ureters (the tubes connecting the kidneys to the bladder). This symptom can be a sign that the tumor is more aggressive and invasive or that your cancer has spread.
What Are the Signs of Advanced Bladder Cancer?
Luckily, about three-fourths of bladder cancer cases are caught before the tumor has grown into the muscle (called non-invasive bladder cancer). For 21% of patients, though, the cancer has already spread into the bladder muscle, the fatty tissues, and/or lymph nodes when they are diagnosed. And in 4% of those cases, the cancer has spread to other parts of the body, most often the lungs, liver, and bones. Sometimes the cancer spreads to the uterus, prostate, and the vagina, so doctors remove them when they remove the bladder.
Again, the following signs don’t always indicate cancer, but they should still always be checked out:
Weight loss, i.e. you’ve lost 15 to 20 pounds over a three-month period without even trying. Don’t get alarmed if you’ve lost five pounds in a month, but if you continue to lose at that rate it’s time to see your doctor.
General fatigue and weakness no matter how much sleep you get
A chronic cough or chest pain (if the bladder cancer has spread to your lungs)
Your skin or the whites of your eyes turn yellow (if the cancer has spread to your liver)
A dull pain on the right side of your abdomen, swelling, or tenderness (if the cancer has spread to the liver)
Sharp ache or discomfort in in your bones that’s hard to control with pain meds (if the cancer has spread to your bones)
More fractures or broken bones (if the cancer has spread to your bones)
When Should I Call My Doctor?
If you see blood in your urine, book an appointment with a urologist, an M.D. who specializes in the urinary tract. A urologist will be able to do more advanced screening tests if it turns out you don’t have an infection or any other reason for those blood cells.
Even if you have bladder cancer, it will most likely be the non-invasive kind. Remember, when tumors are caught at the earliest stage, the five-year survival rate (meaning the number of people who are alive five years after their diagnosis) is 96%. So the odds are definitely in your favor.
But relying solely on your primary provider may delay your diagnosis. A study published in the Urologic Oncology found that primary-care providers only referred their patients with visible blood to urologists about three-fourths of the time—and only 36% of primary docs referred people microscopic levels to a specialist. And your chances of seeing a urologist go way down if you’re a woman. In another study of patients with hematuria, 47% of the men and only 28% of women were referred to a urologist.
One reason: Men have higher rates of bladder cancer (up to four times as many cases as women), so primary care doctors tend to misdiagnose women with UTIs more often, treating them with antibiotics for months rather than sending them to a specialist. When women are finally diagnosed with bladder cancer, the cases are more advanced. And unlike many other cancers, women die more often than men.
The same is true for people of color, male or female. White men are twice as likely to have bladder cancer than African-American men, but African Americans have worse outcomes because their tumors tend to be more aggressive and are caught later, probably because of lower access to health care, cancer treatment centers, and lack of good health insurance. African-American women have the highest odds of dying of all.
The moral of this story? If you have blood in your urine and no infection, be proactive and ask for the referral yourself.
What to Expect at the Urologist's Office
There are several ways doctors diagnose bladder cancer. First, the urologist will ask questions to find out if you’ve had chronic UTIs or blood in the urine before as well as do a physical exam to rule out an enlarged prostate, say, or even check for tumors. If necessary, the next steps will be a urine test, imaging, and a biopsy.
Cytology. A doctor examines your urine to check for abnormal cells as well as bacterial or viral infections. Most of the time, a cytology can’t catch low-grade tumors, though it may be able to spot some malignant cells in more aggressive tumors. It also can’t tell the doctor where these cancer cells are located—they could be from a tumor in your kidney or urethra.
Ultrasound or CT-scan. Your doctor wants to see your entire urinary tract, including the kidneys, in order to check for abnormal spots or masses. Many doctors schedule the scan first in case it picks up something suspicious. If so, you may have the biopsy tests done in the hospital.
Cystoscopy. This test is done in the doctor’s office under local anesthesia. The doctor puts a probe with a light and small camera through your urethra and into your bladder to look for tumors. It’s a mercifully short test, 10 minutes at most. If the urologist finds a superficial tumor that’s under one millimeter (the size of a pencil point), then he or she can burn it off on the spot, send it to pathology, and save you a trip to the OR. But most of the time, doctors remove the tumors in a hospital.
Transurethal resection of bladder tumor (TURBT). Some urologists want to look and biopsy at the same time, especially when imaging has picked up masses or tumors. For that, you’ll go to the hospital as an outpatient and be under anesthesia. The TURBT is similar to the cystoscopy probe, but it has an electric wire loop so the doctor can remove the tumors and then send them to the lab. Doctors will remove any tumors they find, regardless of whether they're benign or not, although an experienced urologist may be able to tell how aggressive a tumor is just by sight.
Just thinking you have bladder cancer is scary, but most of the time, there are other reasons behind your symptoms. And if you are one of the more than 80,000 cases that will be diagnosed this year, just know that there are many new treatments out there that can put you in remission and preserve your quality of life.
- Bladder Cancer Statistics (1): National Cancer Institute/Surveillance, Epidemiology, and End Results Program. (n.d). “Cancer Stat Facts: Bladder Cancer.” seer.cancer.gov/statfacts/html/urinb.html
- Bladder Cancer Statistics (2): American Society of Clinical Oncology. (2019). “Bladder Cancer: Statistics.” cancer.net/cancer-types/bladder-cancer/statistics
- Blood in Urine: World Journal of Urology. (2012). “Accurate Risk Assessment of Patients with Asymptomatic Hematuria for the Presence of Bladder Cancer.” ncbi.nlm.nih.gov/pmc/articles/PMC4004026/
- Carcinoma in Situ: Therapeutic Advances in Urology. (2015). “Management of carcinoma in situ of the bladder: best practice and recent developments.” ncbi.nlm.nih.gov/pmc/articles/PMC4647140/
- Advanced Bladder Cancer Stats: Cancer. (2014). “Trends in Stage-Specific Incidence Rates for Urothelial Carcinoma of the Bladder in the United States: 1988 to 2006.” ncbi.nlm.nih.gov/pmc/articles/PMC3964001/
- Urology Referrals: Urologic Oncology. (2010). “Are patients with hematuria appropriately referred to Urology?” ncbi.nlm.nih.gov/pubmed/19097811
- Gender Differences in Referrals: Urology. (2008). “Patterns of hematuria referral to urologists: does a gender disparity exist?” ncbi.nlm.nih.gov/pubmed/18619657
- Racial Disparities: Cancer. (2009). “Sex and Race in Bladder Cancer: What We Have Learned and Future Directions.” acsjournals.onlinelibrary.wiley.com/doi/full/10.1002/cncr.23997