Bladder cancer is the ninth most common cancer worldwide, and more than 600,000 people are diagnosed with it every year. It is approximately 3–4 times more common in men than in women, and in Türkiye it is likewise among the most common cancers in men. The good news is that bladder cancer frequently announces itself early, with painless blood in the urine. The bad news is that this bleeding is intermittent and, because it "settles on its own", it is the finding most often ignored. In this article we review the symptoms of bladder cancer, what is seen at the earliest stage, how the presentation differs in women, the risk factors and the diagnostic pathway, in the light of current guidelines.

What is bladder cancer?

The bladder is a muscular sac in which urine produced by the kidneys is stored. Its inner surface, which is in contact with urine, is lined by a specialised layer of cells called the urothelium. More than 90% of bladder cancers arise from this layer and are termed urothelial carcinoma. Less common types are squamous cell carcinoma and adenocarcinoma.

The single most important feature determining the treatment and course of bladder cancer is how deeply the tumour has grown into the bladder wall. In approximately three-quarters of newly diagnosed patients, the tumour is confined to the inner lining or to the connective tissue immediately beneath it; these tumours are referred to as non-muscle-invasive (superficial) bladder cancer (NMIBC) and can be treated with the bladder preserved. In the remaining quarter, the tumour has reached the muscle layer (muscle-invasive bladder cancer, MIBC) and requires more extensive treatment.

The most common symptom of bladder cancer: painless blood in the urine

In the great majority of patients, the first and often the only symptom is visible, painless blood in the urine (macroscopic haematuria). The urine may look pink, red, brown or tea-coloured, and clots are sometimes present. Three features of this bleeding are misleading:

• It is painless: Because there is no burning or discomfort, it is dismissed as "nothing serious".
• It is intermittent: It may appear once and then not recur for days, weeks or even months, so seeking advice is postponed on the grounds that "it has stopped".
• The amount is irrelevant: Even very slight bleeding may be caused by a tumour; very little blood is needed to turn the urine red.

In some patients the blood is not visible and is detected only on urinalysis (microscopic haematuria). In this situation, too, assessment is required according to age and risk factors. We cover all causes of blood in the urine, and the investigations used to find them, in detail in our article Blood in Urine (Hematuria): Causes and When It Is Serious.

Other symptoms of bladder cancer

Alongside bleeding, symptoms of bladder irritation may also occur:

• Frequent urination and a sudden, urgent need to pass urine
• A burning sensation when passing urine
• A feeling of incomplete bladder emptying

These symptoms are usually attributed to a urinary tract infection. However, "cystitis" symptoms with a sterile urine culture, or that persist despite antibiotics, should be evaluated for carcinoma in situ (CIS), a superficial but aggressive form of the disease that spreads across the inner lining of the bladder, particularly in people over 50 and in smokers.

Symptoms of advanced bladder cancer

When the tumour has grown through the muscle layer into the surrounding tissues or has spread to other organs, the following symptoms may develop:

• Flank pain caused by obstruction of the tube that drains urine from the kidney (the ureter)
• Pain in the pelvis, groin or rectum
• Swelling of the legs (oedema)
• Bone pain, unintentional weight loss, loss of appetite and fatigue
• Inability to pass urine because of clots

These symptoms indicate that the disease has progressed; the aim is to detect bladder cancer before it reaches this point, at the time of the first episode of bleeding.

Early-stage (stage 1) bladder cancer symptoms

One of the questions patients ask most often is which symptoms appear at the earliest stage. In early-stage bladder cancer (Ta, CIS and T1), the only finding is often painless blood in the urine, or blood detected on urinalysis; in some patients this is accompanied by frequency and burning. Pain, weight loss or a palpable mass are features not of early-stage but of advanced disease. The reassurance "I have no pain and I feel well" therefore does not exclude early-stage bladder cancer.

Bladder cancer symptoms in women

In women the symptoms are the same as in men, but the diagnosis is frequently delayed. The main reasons for this are:

• Blood in the urine is attributed to urinary tract infection, which is more common in women, and is repeatedly dismissed with courses of antibiotics.
• Postmenopausal bleeding is assumed to be a gynaecological problem, and the urinary tract is not investigated.

Studies show that women are diagnosed with bladder cancer at a more advanced stage. Haematuria that persists despite treatment, or that occurs without evidence of infection, warrants urological assessment in women as well. You can read how recurrent urinary tract infections should be managed in our article Recurrent Urinary Tract Infections (Cystitis).

What causes bladder cancer? Risk factors

• Smoking: The most important risk factor, responsible for approximately half of all bladder cancers. Current smokers have approximately 3–4 times the risk of people who have never smoked. Carcinogens in tobacco smoke pass into the bloodstream, are filtered by the kidneys and, as urine is stored, remain in prolonged contact with the bladder lining. Stopping smoking reduces the risk substantially over the years.
• Occupational exposure: Aromatic amines and similar chemicals used in the dye, rubber, leather, textile, metal and petrochemical industries increase the risk.
• Age and sex: The risk rises markedly after the age of 55; men are affected more often.
• Previous treatment: Pelvic radiotherapy and certain chemotherapy drugs, such as cyclophosphamide.
• Chronic bladder irritation: Long-term catheter use, recurrent bladder stones and schistosomiasis, a parasitic infection seen in some countries.
• Arsenic in drinking water and a family history of urothelial cancer.

How is bladder cancer diagnosed?

1. Urinalysis and urine culture: The presence of blood is confirmed and infection is excluded.
2. Imaging: Ultrasound is performed as the first step, but it may fail to show small, flat tumours. For visible haematuria, contrast-enhanced CT urography, which also evaluates the upper urinary tract, is recommended.
3. Cystoscopy: The gold standard for the diagnosis of bladder cancer. A thin, flexible camera is passed through the urethra so that the inner lining of the bladder can be examined directly; the procedure is performed in the outpatient clinic with local anaesthetic gel and takes a few minutes. Cystoscopy may be necessary even when ultrasound and CT are normal. We describe the procedure step by step in Cystoscopy: What It Is, How It Is Done and Does It Hurt?
4. Urine cytology: The urine is examined for cancer cells; this is particularly helpful in detecting high-grade tumours and carcinoma in situ.
5. TURBT (transurethral resection of bladder tumour): If a tumour is seen at cystoscopy, it is removed completely by a closed (endoscopic) approach through the urethra. The procedure is both diagnostic and the initial treatment; the pathology report establishes the type and grade of the tumour and how deeply it has invaded the bladder wall.

In muscle-invasive disease, staging is completed with imaging of the chest, abdomen and pelvis to assess spread.

Treatment options at a glance

Treatment is planned according to the stage and risk group:

• Non-muscle-invasive tumours: The tumour is removed by TURBT. In low-risk patients, a single dose of a chemotherapy agent is instilled into the bladder after the procedure; in intermediate- and high-risk patients, courses of intravesical BCG or chemotherapy are used to reduce the risk of recurrence.
• Muscle-invasive tumours: In suitable patients, the standard treatment is neoadjuvant chemotherapy followed by removal of the bladder (radical cystectomy) and reconstruction of the urinary tract; this operation can also be performed robotically (Robotic Surgery). In selected patients, chemoradiotherapy with preservation of the bladder (trimodality bladder-sparing therapy) is also an option.
• Metastatic disease: Newer treatments such as chemotherapy, immunotherapy and antibody–drug conjugates have markedly prolonged survival in recent years.

For details of the treatment options, please see our Bladder Cancer Treatment page.

Does bladder cancer come back?

One of the most important characteristics of non-muscle-invasive bladder cancer is its tendency to recur in another part of the bladder after treatment. For this reason, regular cystoscopic surveillance is carried out after treatment, at intervals determined by the risk group. Keeping to the follow-up schedule ensures that recurrent tumours are detected while they are still small and easily treatable.

Is bladder cancer fatal? Survival by stage

The most important factor determining survival in bladder cancer is the stage at diagnosis. According to data from the US National Cancer Institute (SEER), five-year relative survival is above 95% for disease confined to the inner lining (in situ), approximately 70% for disease confined to the bladder, approximately 40% for disease that has spread to the surrounding tissues or lymph nodes, and below 10% for disease that has spread to distant organs. These figures show clearly how vital it is to seek medical advice at the first episode of bleeding.

Frequently Asked Questions

What is the first sign of bladder cancer?

The most common first sign is painless, visible blood in the urine. The bleeding may be intermittent and may stop on its own; this does not mean that the tumour has gone.

Can a blood test detect bladder cancer?

There is no blood test that shows bladder cancer. Blood may be detected on urinalysis, but the diagnosis is made by cystoscopy and pathological examination of the tissue removed.

Can bladder cancer be seen on an ultrasound?

Tumours that have reached a certain size can be seen on ultrasound; however, small, flat tumours and carcinoma in situ may be missed. A normal ultrasound does not replace the cystoscopy that is required when there is blood in the urine.

Can you die from bladder cancer?

Bladder cancer detected at an early stage is usually treatable, and five-year survival reaches up to 95%. The prognosis is worse when the disease has spread, which is why seeking advice early is decisive.

Are bladder cancer symptoms different in women?

The symptoms are the same; however, because blood in the urine is often attributed to infection or to gynaecological causes in women, the diagnosis may be delayed. Bleeding that does not respond to treatment, or that recurs, requires urological assessment.

Does quitting smoking reduce the risk of bladder cancer?

Yes. In people who stop smoking, the risk of bladder cancer falls markedly over the years. There is also evidence that stopping smoking reduces the risk of recurrence in patients already diagnosed with bladder cancer.

What kind of doctor treats bladder cancer?

Diagnosis and surgical treatment are undertaken by urologists experienced in uro-oncology; medical oncology and radiation oncology join the team depending on the treatment plan.

This article is intended for general information only and does not constitute individual medical advice. Please consult your physician for diagnosis and treatment.

References

1. European Association of Urology. EAU Guidelines on Non-muscle-invasive Bladder Cancer (TaT1 and CIS). Arnhem: EAU Guidelines Office; 2025. uroweb.org/guidelines/non-muscle-invasive-bladder-cancer
2. European Association of Urology. EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer. Arnhem: EAU Guidelines Office; 2025. uroweb.org/guidelines/muscle-invasive-and-metastatic-bladder-cancer
3. Barocas DA, Boorjian SA, Alvarez RD, et al. Microhematuria: AUA/SUFU Guideline. J Urol 2020;204(4):778-786.
4. Freedman ND, Silverman DT, Hollenbeck AR, Schatzkin A, Abnet CC. Association between smoking and risk of bladder cancer among men and women. JAMA 2011;306(7):737-745.
5. Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2024;74(3):229-263.
6. National Cancer Institute. SEER Cancer Stat Facts: Bladder Cancer. seer.cancer.gov/statfacts/html/urinb.html