Bladder Cancer: Signs, Diagnosis & Treatment | Dr. Theodore Cisu

The short answer: The most common warning sign of bladder cancer is blood in the urine, usually without any pain. It is diagnosed by looking inside the bladder with a thin camera (cystoscopy) and removing the tumor through the urethra (TURBT). Most bladder cancers are found before they grow into the bladder muscle and can be treated while keeping the bladder. Cancer that has reached the muscle needs more intensive care, which often includes surgery to remove the bladder.

Written by Theodore Cisu, MD, board-certified urologist. Based on the AUA/SUO guideline on non-muscle invasive bladder cancer (2026 amendment) and the AUA/ASCO/SUO guideline on non-metastatic muscle-invasive bladder cancer (2024 amendment). Last reviewed November 2026.

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What is bladder cancer?

The bladder is a hollow, muscular organ that stores urine. Its inside is covered by a thin lining. Most bladder cancers start in the cells of this lining. Doctors call this urothelial carcinoma.

The most important question after diagnosis is how deep the cancer goes. Cancer that stays in the lining, or the thin layer just under it, is called non-muscle-invasive. Cancer that grows into the thick muscle wall of the bladder is called muscle-invasive. The two are treated very differently.

Warning signs of bladder cancer

• Blood in the urine. Urine may look pink, red or cola-colored, or you may see clots. It is often painless, and it may come and go.
• Blood found only on a urine test. Your doctor may see red blood cells under the microscope even when your urine looks normal.
• Bladder symptoms with no infection. Burning, urgency or going often, especially if antibiotics don't help.
• Pain in the side, back or pelvis. This is less common and usually happens later.

Blood in the urine that you can see should always be checked by a urologist, even if it happened only once and went away. Most of the time the cause is something else, such as an infection, a stone or an enlarged prostate. It still needs a proper look.

Who is at risk?

• Smoking is the biggest known risk factor. Quitting lowers risk over time and also helps after a diagnosis.
• Older age, and being male
• Long-term work exposure to certain chemicals, such as those used in dyes, rubber, leather and paint
• Past radiation to the pelvis or certain chemotherapy medicines

How is bladder cancer diagnosed?

Urine tests

A urinalysis checks for blood and infection. Urine cytology looks for cancer cells. Newer urine marker tests can help in some situations.

Office cystoscopy

A thin, flexible camera is passed through the urethra into the bladder after numbing gel is applied. You are awake, and it takes a few minutes. This lets your urologist see the whole bladder lining. Dr. Cisu performs office cystoscopy at his clinics.

Imaging of the kidneys and ureters

The same kind of cancer can also form in the kidneys and ureters, the tubes that drain them. The AUA guideline calls for imaging of this upper urinary tract as part of the first workup. This is usually a CT scan with contrast.

TURBT (transurethral resection of bladder tumor)

Under anesthesia, the tumor is removed through the urethra with a scope. There are no skin incisions. The tissue goes to a pathologist, who reports the grade (how aggressive the cells look) and the stage (how deep it goes). Dr. Cisu performs TURBT at Augusta Health. Enhanced cystoscopy, such as blue light, can help spot tumors. It is an option your urologist can discuss, and Dr. Cisu can coordinate a referral when it fits. For tumors that look low or intermediate risk, the guideline recommends a single dose of chemotherapy placed in the bladder within 24 hours of TURBT, unless there is a concern about a deep resection. Some high-grade tumors need a second resection within about six weeks to make sure nothing was missed.

Non-muscle-invasive bladder cancer: risk groups and treatment

Non-muscle-invasive cancers are sorted into low, intermediate and high risk, based on grade, size, number of tumors, whether it has come back, and whether a flat high-grade lesion called carcinoma in situ (CIS) is present. The 2026 AUA/SUO amendment updated these risk groups. Your group guides treatment and how often you need checkups.

Low risk

TURBT, often with the single post-surgery chemotherapy dose, followed by regular surveillance cystoscopy. If small low-grade tumors come back, the 2026 amendment added options for some people: watching them closely, treating them in the office, or using medicine placed in the bladder to dissolve them. These can spare some people a trip to the operating room.

Intermediate risk

Many people are offered a course of weekly treatments placed in the bladder through a small catheter. This may be chemotherapy or BCG. If the cancer responds fully to BCG, maintenance BCG may be continued for about a year.

High risk and BCG

BCG is a weakened germ, related to the tuberculosis vaccine, that wakes up the immune system in the bladder lining. For newly diagnosed high-risk cancer, the guideline calls for a six-week induction course of BCG, usually followed by maintenance treatments. Common side effects are bladder irritation and a day or two of flu-like feelings.

When BCG stops working

If high-grade cancer stays or comes back within a year of adequate BCG, it is called BCG-unresponsive. For people who are healthy enough, removing the bladder (radical cystectomy) is an important option to discuss. For people who can't have or don't want surgery, the guideline points to other treatments placed in the bladder, immunotherapy medicines given by vein, or clinical trials. Several new treatments have become available in recent years.

Treatment for muscle-invasive bladder cancer

• Chemotherapy before surgery. For people who can safely receive it, cisplatin-based chemotherapy before surgery is recommended. A medical oncologist directs this part of care.
• Radical cystectomy. The bladder and nearby lymph nodes are removed. Depending on the person, nearby organs may also be removed.
• A new way for urine to leave the body. Options include an ileal conduit (urine drains into a small bag on the belly), a neobladder (a new bladder made from intestine, so you urinate through the urethra) or an internal pouch that you drain with a catheter.
• Bladder-sparing treatment. Some people are candidates for a combination of TURBT, chemotherapy and radiation instead of cystectomy.
• Treatment after surgery. Immunotherapy may be recommended after surgery for some people at higher risk of the cancer coming back.

Bladder removal surgery

Removing the bladder is a major surgery. Dr. Cisu does not perform cystectomy. When it is the right option, he coordinates your care with a bladder cancer surgical team. Your care team, including medical and radiation oncology when needed, will help you weigh every option, including bladder-sparing ones.

Life after treatment

Bladder cancer often comes back, especially non-muscle-invasive types. That's why follow-up cystoscopy and imaging are part of the plan for years. The first check is usually a few months after treatment. Visits are spaced out over time if things stay clear. Stopping smoking is one of the most helpful things you can do.

When to see a urologist

• Any blood in your urine that you can see, even once
• Blood in the urine found on a routine test
• Bladder symptoms that don't go away and aren't from an infection
• A CT or ultrasound that shows something in your bladder

When it's an emergency

Go to the emergency room if you can't pass urine because of clots, have heavy bleeding with many clots, or have fever with urinary symptoms.

Seeing Dr. Cisu for bladder cancer

You can start with a telehealth visit from anywhere in Virginia. Our office can request your records, urine tests and imaging so Dr. Cisu reviews them before you talk. Second opinions are welcome, including after a recent diagnosis. In-person visits and office cystoscopy are available at our clinics in Charlottesville and Fishersville. No referral is needed. Book an appointment.

Frequently asked questions

Is blood in the urine always cancer?

No. Most blood in the urine comes from other causes, such as infection, kidney stones or an enlarged prostate. Because bladder cancer is one possible cause, visible blood should always be checked by a urologist.

Does a cystoscopy hurt?

Most people describe office cystoscopy as uncomfortable more than painful. Numbing gel is used, the scope is thin and flexible, and the exam takes only a few minutes. Some people notice mild burning when they urinate for a day or so afterward.

What is BCG treatment like?

BCG is placed in the bladder through a small catheter in the office. You hold it for a period of time and then urinate it out. Treatments are usually weekly during the first course. Bladder irritation and brief flu-like symptoms are common and usually short-lived.

Can bladder cancer come back after treatment?

Yes. Non-muscle-invasive bladder cancer comes back fairly often, which is why regular checkups matter. Finding a recurrence early usually means it can be treated with a smaller procedure.

Can you live a normal life without a bladder?

Many people return to work, travel and their usual activities after cystectomy. There is an adjustment period with any type of urinary diversion. Your care team will help you choose the type that fits your health and lifestyle.

Is non-muscle-invasive bladder cancer curable?

Many people with non-muscle-invasive bladder cancer are treated successfully and keep their bladder. The outlook depends on the risk group, and ongoing surveillance is an important part of care.

Sources

• American Urological Association. Non-Muscle Invasive Bladder Cancer Guideline Amendment (AUA/SUO, 2026).
• American Urological Association. Non-Metastatic Muscle-Invasive Bladder Cancer Guideline Amendment (AUA/ASCO/SUO, 2024).

This article is for general education and isn't a substitute for medical advice. Talk with your own doctor about your situation. If you can't urinate, have heavy bleeding with clots, or have a fever, call 911 or go to the nearest emergency room.