Bladder cancer is caused by changes to the cells of the bladder. It is often linked with exposure to certain chemicals.

What is cancer?

Cancer begins with a change (mutation) in the structure of the DNA in cells, which can affect how they grow. This means cells grow and reproduce uncontrollably, producing a lump of tissue called a tumour.

Increased risk

It is not always known what causes the cell changes that lead to bladder cancer, but several things have been identified that can significantly increase your risk of developing it. 

Smoking

Smoking is the single biggest risk factor for bladder cancer. This is because tobacco contains cancer-causing (carcinogenic) chemicals.

If you smoke for many years, these chemicals pass into your bloodstream and are filtered by the kidneys into your urine. The bladder is repeatedly exposed to these harmful chemicals, as it acts as a store for urine. This can cause changes to the cells of the bladder lining that may lead to bladder cancer.

It is estimated that around half of all cases of bladder cancer are related to smoking. People who smoke may be up to six times more likely to develop bladder cancer than non-smokers.

Exposure to chemicals

Exposure to certain industrial chemicals is the second biggest risk factor. Previous studies have estimated this may account for around 25% of cases.

Chemicals known to increase the risk of bladder cancer include:

• aniline dyes
• 2-Naphthylamine
• 4-Aminobiphenyl
• xenylamine
• benzidine

Occupations linked to an increased risk of bladder cancer are manufacturing jobs involving:

• dyes
• textiles
• rubbers
• paints
• plastics
• leather tanning

Some non-manufacturing jobs have also been linked to an increased risk of bladder cancer. These include taxi or bus drivers as a result of their regular exposure to the chemicals present in diesel fumes.

The link between bladder cancer and these types of occupations was discovered in the 1950s and 1960s. Since then, regulations relating to exposure to cancer-causing chemicals have been made much more rigorous and many of the chemicals listed above have been banned.

However, these chemicals are still linked with cases of bladder cancer now, as it can take up to 30 years after initial exposure to the chemicals before the condition starts to develop.

Other risk factors

Other things known to increase your risk of bladder cancer include:

• radiotherapy to treat previous cancers near the bladder, such as bowel cancer
• previous treatment with certain chemotherapy medications, such as cyclophosphamide and cisplatin
• having a tube in your bladder (an indwelling catheter) for a long time because you have nerve damage that has resulted in paralysis
• long-term or repeated urinary tract infections (UTI)
• an untreated infection called schistosomiasis, which is caused by a parasite that lives in fresh water – this is very rare in the UK

How does bladder cancer spread?

Bladder cancer usually begins in the cells of the bladder lining. In some cases it may then spread into surrounding bladder muscle. If the cancer penetrates this muscle, it can spread to other parts of the body, usually through the lymphatic system.

If bladder cancer spreads to other parts of the body, such as other organs, it is known as metastatic bladder cancer.

A diagnosis of bladder cancer, and some treatments for the condition, can have a significant impact on your life.

Emotional impact

The emotional impact of living with bladder cancer can be huge. Many people report experiencing a kind of “rollercoaster” effect. For example, you may feel down at receiving a diagnosis, up when the cancer is removed, and down again as you try to come to terms with the after-effects of your treatment.

This type of emotional disruption can sometimes trigger feelings of depression. Signs that you may be depressed include:

• having continuous feelings of sadness or hopelessness
• no longer taking pleasure in the things you enjoy

Contact your GP for advice if you think you may be depressed. There is a range of relatively successful treatments for depression, including antidepressant medication and therapies such as cognitive behavioural therapy (CBT).

Read more about coping with cancer.

Urinary diversion

If your bladder is removed, an alternative way of passing urine out of your body will be created during the operation. This is called urinary diversion.

There are various types of urinary diversion, which are described below. In some cases you may be able to make a choice based on your personal preferences. However, certain treatment options will not be suitable for everyone.

Your multidisciplinary team (MDT) will provide information about the options suitable for you.

Urostomy

A urostomy is carried out during a radical cystectomy. A small section of the small bowel is removed and connected to your ureters (the two tubes that normally carry urine out of the kidneys).

The surgeon then creates a small hole in the surface of your abdomen and the open end of the removed bowel is placed in this hole, creating an opening known as a stoma.

A special waterproof bag is placed over the stoma to collect urine. A stoma nurse will teach you how to care for your stoma and how and when to change the bag.

The Urostomy Association is a UK-based charity that provides information and assistance to people who have recently had, or are about to have, a urostomy.

Continent urinary diversion

Continent urinary diversion is similar to a urostomy, but without an external bag. Instead, a section of your bowel is used to create a pouch inside your body that stores urine.

The ureters are connected to the pouch and the pouch is connected to an opening in the abdominal wall. A valve in the opening (stoma) prevents urine leaking out.

The pouch is emptied using a thin, flexible tube (catheter). Most people need to empty their pouch about four or five times a day.

Bladder reconstruction

In some cases it may be possible to create a new bladder, known as a neobladder. This involves removing a section of your bowel and reconstructing it into a balloon-like sac, before connecting it to your urethra (the tube that carries urine out of the body) at one end and your ureters at the other end. However, bladder reconstruction is not suitable for everyone. 

You will be taught how to empty your neobladder by relaxing the muscles in your pelvis while tightening the muscles in your abdomen at the same time.

Your neobladder will not contain the same types of nerve endings as a real bladder, so you will not get the distinctive sensation that tells you that you need to pass urine. Some people experience a feeling of fullness inside their abdomen, while others have reported that they feel like they need to pass wind.

Because of the loss of normal nerve function, most people with a neobladder will experience some episodes of urinary incontinence (involuntary passing of urine), which usually occurs during the night while they are asleep.

You may find it useful to empty your neobladder at set times during the day, including before you go to bed, to help prevent incontinence.

Guy’s and St Thomas’ NHS Foundation Trust has more information and advice about treatments for bladder cancer.

Sexual problems

Erectile dysfunction

Contact your MDT if you lose the ability to obtain or maintain an erection after a radical cystectomy. It may be possible for you to be treated with a type of medicine known as phosphodiesterase type 5 inhibitors (PDE5). PDE5s work by increasing the blood supply to your penis.

Sometimes PDE5s are combined with a device called a vacuum pump, which consists of a cylinder connected to a pump. The penis is placed inside the cylinder and the air is pumped out. This creates a vacuum that causes blood to flow into the penis. A rubber ring is then placed around the base of the penis, which allows an erection to be maintained for around 30 minutes.

Read more about treating erectile dysfunction.

Narrowing of the vagina

Both radiotherapy and cystectomy can cause a woman’s vagina to become shortened and narrowed, which can make penetrative sex painful or difficult.

There are two main treatment options available if you have a narrowed vagina. The first is to apply hormonal cream to the area, which should help to increase moisture inside your vagina.

The second is to use vaginal dilators. These are plastic cone-shaped devices of various sizes that are designed to gently stretch your vagina and make it more supple.

It is usually recommended you use dilators for a five to 10-minute period every day, starting with the dilator that fits in easiest first and gradually increasing the size as your vagina stretches over the following weeks.

Many women find this an embarrassing issue to discuss, but the use of dilators is a well-recognised treatment for narrowing of the vagina. Your specialist cancer nurse should be able to provide more information and advice.

You may find that the more often you have penetrative sex, the less painful it becomes. However, it may be several months before you feel emotionally ready to be intimate with a sexual partner.

The Macmillan Cancer Support website has some excellent information and a video about sexuality and cancer.

If you have symptoms of bladder cancer, such as blood in your urine, you should see your GP.

Your GP may ask about your symptoms, family history and whether you have been exposed to any possible causes of bladder cancer, such as smoking.

In some cases your GP may request a urine sample so it can be tested in a laboratory for traces of blood, bacteria or abnormal cells.

Your GP may also carry out a physical examination of your rectum and vagina, as bladder cancer sometimes causes a noticeable lump that presses against them.

If your doctor suspects bladder cancer, they will refer you to a hospital for further tests. Some hospitals have specialist clinics for people with blood in their urine (haematuria), whereas others have specialist urology departments for people with urinary tract problems.

At the hospital

If you are referred to a hospital specialist, there are several tests you may have to check for bladder cancer. These are outlined below.

Urine tests

You may be asked to provide a urine sample so it can be checked for any infection or abnormal cells. The test for abnormal cells is called urinary cytology.

Urinary cytology is not 100% accurate. It can sometimes detect abnormal cells even though there is no cancer present (a false-positive result), or it can fail to detect abnormal cells when cancer is present (a false-negative result). Urinary cytology is therefore used to help diagnose bladder cancer, rather than to provide a definitive diagnosis.

Cystoscopy

Cystoscopy uses an instrument known as a cytoscope (a thin tube with a camera and light at the end) to examine the inside of your bladder. The procedure usually takes about five minutes.

During a cystoscopy a local anaesthetic gel is applied to your urethra (the tube through which you urinate) so you don’t feel any pain. The gel also helps the cystoscope to pass into the urethra more easily.

Biopsy

If abnormalities are found in your bladder during a cystoscopy, it is likely you will be asked to return so a sample of bladder tissue can be removed for further testing. This is known as a biopsy.

A biopsy is often carried out using a procedure known as transurethral resection of a bladder tumour (TURBT). The procedure is carried out under general anaesthetic.

See treating bladder cancer for more information about the TURBT procedure.

Further testing

You may need further tests if the results of your biopsy show cancerous cells in the lining of your bladder. These will help determine whether the cancer has spread beyond the lining of your bladder and, if so, how far it has spread.

Further tests can include:

• computerised tomography (CT) scan – a series of X-rays are taken to create a detailed picture of the inside of the body; you may be given an injection or drink of dye beforehand to highlight abnormal areas
• intravenous (IV) urogram – after dye is injected into your bloodstream, X-rays are used to study it as it passes through your urinary system

Staging and grading

Once these tests have been completed it should be possible to tell you the grade of the cancer and what stage it is.

Grading is a measurement of how likely a cancer is to spread. The grade of a cancer is usually described using a number system ranging from G1-G3. High-grade cancers are more likely to spread than low-grade cancers. 

Staging is a measurement of how far the cancer has spread. Lower stage cancers are smaller and have a better chance of successful treatment. The most widely used staging system for bladder cancer is known as the TNM system, where:

• T stands for how far into the bladder the tumour has grown
• N stands for whether the cancer has spread into nearby lymph nodes
• M stands for whether the cancer has spread into another part of the body (metastasis), such as the lungs

T stages

The T staging system is as follows:

• TIS or CIS (carcinoma in situ) – a very early high-grade cancer confined to the innermost layer of the bladder lining 
• Ta – the cancer is just in the innermost layer of the bladder lining
• T1 – the cancerous cells have started to grow into the connective tissue beyond the bladder lining

Bladder cancer up to the T1 stage is usually called early bladder cancer or non-muscle invasive bladder cancer.

If the tumour grows larger than this, it is usually called muscle-invasive bladder cancer and is categorised as:

• T2 – the cancer has grown through the connective tissue into the bladder muscle
• T3 – the cancer has grown through the layer of muscles into the surrounding layer of fat

If the tumour grows larger than the T3 stage, it is considered to be advanced bladder cancer and is categorised as:

• T4 – the cancer has spread outside the bladder into surrounding organs 

N stages

The N staging system is as follows:

• N0 – there are no cancerous cells in any of your lymph nodes
• N1 – there are cancerous cells in just one of your lymph nodes in your pelvis
• N2 – there are cancerous cells in two or more lymph nodes in your pelvis
• N3 – there are cancerous cells in one or more of your lymph nodes (known as common iliac nodes) found in your groin

M stages

There are only two options in the M system:

• M0 – where the cancer has not spread to another part of the body
• M1 – where the cancer has spread to another part of the body, such as the bones, lungs or liver

The TNM system can be difficult to understand, so don’t be afraid to ask your care team questions about your test results and what they mean for your treatment and outlook.

Read more about understanding your test results.

Bladder cancer is where a growth of abnormal tissue known as a tumour develops in the lining of the bladder. In some cases the tumour spreads into the surrounding muscles.

The most common symptom of bladder cancer is blood in your urine, which is usually painless.

If you notice blood in your urine, even if it comes and goes, you should visit your GP so the cause can be investigated.

Read more about the symptoms of bladder cancer.

Types of bladder cancer

Once diagnosed, bladder cancer can be classified by how far it has spread. 

If the cancerous cells are contained inside the lining of the bladder, doctors describe it as superficial or non-muscle-invasive bladder cancer. This is the most common type of bladder cancer, accounting for 7 out of 10 cases. Most people do not die as a result of this type of bladder cancer.

When the cancerous cells spread beyond the lining into the surrounding muscles of the bladder, it’s referred to as muscle-invasive bladder cancer. This is less common, but has a higher chance of spreading to other parts of the body and can be fatal.

Read more about diagnosing bladder cancer.

Why does bladder cancer happen?

Most cases of bladder cancer appear to be caused by exposure to harmful substances that lead to abnormal changes in the bladder’s cells over the course of many years. 

Tobacco smoke is a common cause and it is estimated that half of all cases of bladder cancer are caused by smoking.

Contact with certain chemicals previously used in manufacturing is also known to cause bladder cancer. However, these substances have since been banned.

Read more about the causes of bladder cancer and preventing bladder cancer.

Treating bladder cancer

In cases of non-muscle-invasive bladder cancer, it is usually possible to remove the cancerous cells while leaving the rest of the bladder intact.

This is done using a surgical technique called transurethral resection of a bladder tumour (TURBT). This may be followed by a dose of chemotherapy medication directly into the bladder to reduce the risk of the cancer returning.

In cases with a higher risk of recurrence, a medication known as Bacillus Calmette-Guérin (BCG) may be injected into the bladder to reduce the risk of the cancer returning.

Treatment for muscle-invasive bladder cancer may involve surgically removing the bladder in an operation known as a radical cystectomy.

When the bladder is removed, you will need another way of collecting your urine. Possible options include making an opening in the abdomen so urine can be passed into an external bag, or constructing a new bladder out of a section of bowel. This will be done at the same time as a radical cystectomy.

If it’s possible to avoid removing the bladder or if surgery is not suitable, a course of radiotherapy and chemotherapy may be recommended. Chemotherapy may sometimes be used on its own before surgery or before being combined with radiotherapy.

After treatment for all types of bladder cancer, you will have regular follow-up tests to check for signs of recurrence.

Read more about treating bladder cancer.

Who is affected?

About 10,000 people are diagnosed with bladder cancer every year.

The condition is more common in older adults, with the average age at diagnosis being 68 years old.

Rates of bladder cancer are four times higher in men than in women, possibly because in the past men were more likely to smoke and work in the manufacturing industry.

The list below is a combination of the and brand names of medicines available in the UK. Each name provides a link to a separate website (Medicine Guides) where you can find detailed information about the medicine. The information is provided as part of an on-going medicine information project between NHS Direct, Datapharm Communications Ltd and other organisations.

The medicines listed below hold a UK licence to allow their use in the treatment of this condition. medicines are not included.

The list is continually reviewed and updated but it may not be complete as the project is still in progress and guides for new medicines may still be in development.

If you are taking one of these medicines for a different condition, or your medicine for this condition is not mentioned here at all, speak to your prescriber, GP or pharmacist, or contact NHS Direct on 0845 46 47.

It is not always possible to prevent bladder cancer, but you can reduce your risk of contracting the disease.

Stopping smoking

If you smoke, giving up is the best way to reduce your risk of developing bladder cancer and preventing it from recurring.

If you decide to stop smoking, your GP will be able to refer you to the NHS Stop Smoking Service, which will provide dedicated help and advice about the best ways to give up smoking.

You can also call the NHS Smokefree helpline on 0300 123 1044 (7am to 11pm). The specially trained helpline staff will offer you free expert advice and encouragement.

If you are committed to giving up smoking but do not want to be referred to a stop smoking service, your GP should be able to prescribe medical treatment to help with any withdrawal symptoms you may experience after giving up.

For more information and advice about giving up smoking, see treatment for quitting smoking and stop smoking.

Workplace safety

Your risk of bladder cancer could be increased if your job involves exposure to certain chemicals. Occupations linked to an increased risk of bladder cancer are manufacturing jobs that involve the following substances:

• rubber
• dyes
• textiles
• plastic
• leather tanning
• diesel fumes

Nowadays, there are rigorous safety protocols in place designed to minimise your risk of exposure, and chemicals known to increase the risk of bladder cancer have been banned. If you are uncertain about what these protocols involve, talk to your line manager or health and safety representative.

If you are concerned your employer may be disregarding recommendations about workplace safety, you should contact the Health and Safety Executive for advice.

Diet

There is some evidence to suggest a diet high in fruit and vegetables and low in fat can help prevent bladder cancer.

Even though this evidence is limited, it is a good idea to follow this type of healthy diet as it can help prevent other types of cancer, such as bowel cancer, as well as serious health conditions, such as high blood pressure (hypertension), stroke and heart disease.

A low-fat, high-fibre diet is recommended, including plenty of fresh fruit and vegetables (five portions a day) and whole grains. Limit the amount of salt that you eat to no more than 6g (0.2oz) a day (one teaspoon) because too much can increase your blood pressure.

You should try to avoid foods that contain a type of fat called saturated fat, as it can increase your cholesterol levels.

Foods high in saturated fat include:

• meat pies
• sausages and fatty cuts of meat
• butter
• ghee (a type of butter often used in Indian cooking)
• lard
• cream
• hard cheese
• cakes and biscuits
• foods that contain coconut or palm oil

However, a balanced diet should include a small amount of unsaturated fat because this will actually help control your cholesterol levels.

Foods high in unsaturated fat include:

• oily fish
• avocados
• nuts and seeds
• sunflower, rapeseed, olive and vegetable oils

Read more about healthy eating and facts about fat.

The Map of Medicine is used by doctors throughout the NHS to determine the best treatment options for their patients. NHS Choices offers everyone in England exclusive and free access to this cutting-edge internet resource, which lets you see exactly what your doctor sees.

The information in the Map has been approved by the UK’s leading clinical experts, is based on the best available clinical evidence, and is continually updated. To take advantage of this unique resource go to:

Map of Medicine: bladder cancer

Blood in your urine is the most common symptom of bladder cancer.

The medical name for this is haematuria and it is usually painless. You may notice streaks of blood in your urine or the blood may turn your urine brown. The blood is not always noticeable and it may come and go.

Less common symptoms of bladder cancer include:

• a need to urinate on a more frequent basis
• sudden urges to urinate
• a burning sensation when passing urine

If bladder cancer reaches an advanced stage and begins to spread, symptoms can include:

• pelvic pain
• bone pain
• unexplained weight loss
• swelling of the legs

When to seek medical advice

If you ever have blood in your urine – even if it comes and goes – you should visit your GP so the cause can be investigated.

Having blood in your urine does not mean that you definitely have bladder cancer, as there are other more common causes. These include a bladder infection such as cystitis, kidney stones or an enlarged prostate gland in men.

The treatment options for bladder cancer largely depend on how advanced the cancer is.

Treatments usually differ between early stage, non-muscle-invasive bladder cancer and more advanced muscle-invasive bladder cancer.

Multidisciplinary teams (MDTs)

All hospitals use multidisciplinary teams (MDTs) to treat bladder cancer. These are teams of specialists that work together to make decisions about the best way to proceed with your treatment.

Members of your MDT may include:

• a urologist – a surgeon specialising in treating conditions affecting the urinary tract
• a clinical oncologist – a specialist in chemotherapy and radiotherapy
• a pathologist – a specialist in diseased tissue
• a radiologist – a specialist in detecting disease using imaging techniques
• a specialist cancer nurse – who will usually be your first point of contact with the rest of the team

Deciding what treatment is best for you can be difficult. Your MDT will make recommendations, but remember that the final decision is yours. 

Before discussing your treatment options, you may find it useful to write a list of questions to ask your MDT. 

Non-muscle-invasive bladder cancer

Your treatment plan

If you have been diagnosed with non-muscle-invasive bladder cancer (stages CIS, Ta and T1), your recommended treatment plan will depend on the risk of the cancer returning or spreading beyond the lining of your bladder.

This risk is calculated using a series of factors, including:

• the number of tumours present in your bladder
• whether the tumours are larger than 3cm (one inch) in diameter
• whether you have had bladder cancer before
• the grade of the cancer cells

See diagnosing bladder cancer for more information about the staging and grading of the condition.

If the risk of your cancer returning or spreading is low, treatment will involve surgery to remove the tumours followed by a single dose of chemotherapy into your bladder.

If the risk of your cancer returning or spreading is moderate, you may be given a longer course of chemotherapy into your bladder after you’ve had surgery.

If the risk of your cancer returning or spreading is high, you may be given a course of Bacillus Calmette-Guérin (BCG) treatment into your bladder after you’ve had surgery.

These treatments are discussed in more detail below.

Surgery

The standard surgical treatment for non-muscle-invasive bladder cancer is known as transurethral resection of a bladder tumour (TURBT) procedure. In most cases this can be performed at the same time as a biopsy.

TURBT is carried out under general anaesthetic. The surgeon uses an instrument called a cystoscope to locate the visible tumours and cuts them away from the lining of the bladder. The wounds are then sealed (cauterised) using a mild electric current. 

If you experience significant bleeding afterwards, a flexible tube called a catheter may be inserted into your urethra and passed up into your bladder. The catheter will be used to drain away any blood and debris from your bladder and may be kept in place for several days.

Most people are able to leave hospital less than 48 hours after having TURBT and are able to resume normal physical activity within two weeks.

Chemotherapy

After surgery, you may be given a dose of chemotherapy directly into your bladder. This will be after you have recovered from the effects of the general anaesthetic.

A different type of chemotherapy (intravesical chemotherapy) is used directly into your bladder using a catheter (rather than affecting the whole body). The solution is kept in your bladder for about an hour before being drained away.

Some residue of the chemotherapy medication may be left in your urine, which could severely irritate your skin. It helps if you urinate while sitting down and that you are careful not to splash yourself or the toilet seat. After passing urine, wash the skin around your genitals with soap and water.

Side effects of intravesical chemotherapy can include a skin rash or irritation and inflammation of the bladder lining. This can cause a frequent need to urinate and pain when urinating. However, this should pass within a few days. You may also feel very tired or develop a rash.

If your cancer is at a low risk of spreading, you should not need additional chemotherapy treatment. However, if there is a moderate or high risk of the cancer spreading, you may be given additional courses of chemotherapy, usually once a week over six weeks.

If you are sexually active, it is important that you use a barrier method of contraception, such as a condom, while you are having intravesical chemotherapy. This is because the medication may be present in your semen or vaginal fluids, which can cause irritation.

You also shouldn’t try to get pregnant or father a child while having intravesical chemotherapy, as the medication can increase the risk of having a child with birth defects.

Bacillus Calmette-Guérin (BCG) treatment

After surgery, you may also be treated with a variant of the BCG vaccine. This is used to help prevent recurrence of bladder cancer when there is a high risk of it returning.

The BCG vaccine was originally used to treat tuberculosis (TB), but it has also proved to be an effective treatment against bladder cancer. Exactly how the BCG vaccine works is still unclear.

The BCG vaccine is given in the same way as intravesical chemotherapy. The vaccine is passed into your bladder through a catheter and left in your bladder for two hours before being drained away.

As with intravesical chemotherapy, you should take precautions such as sitting down while urinating to ensure that urine does not get onto your skin or the toilet seat.

Most people require weekly treatments over a six-week period. Depending on your circumstances, maintenance therapy may also be recommended. This involves receiving further doses of the BCG once a week for three weeks, with six month intervals. Maintenance therapy usually lasts for three years.

Chemotherapy is usually preferred to BCG treatment because the side effects are less severe. Common side effects of BCG can include:

• a frequent need to urinate
• pain when urinating
• blood in your urine (haematuria)
• flu-like symptoms, such as tiredness, fever and aching
• urinary tract infections

Muscle-invasive bladder cancer

Your treatment plan

The recommended treatment plan for muscle-invasive bladder cancer will depend on how far the cancer has spread. See diagnosing bladder cancer for more information about staging.

With T2 and T3 bladder cancer, treatment aims to cure the condition if possible, or at least control it for a long time.

There is only a small chance of a cure for T4 bladder cancer, but treatment may be able to control the symptoms and slow the spread of the cancer.

The different treatment options are outlined below.

Surgery

The most widely used type of surgery for muscle-invasive bladder cancer is a radical cystectomy.

This removes the entire bladder as well as nearby lymph nodes, part of the urethra, the prostate (in men), and the cervix and womb (in women).

During a radical cystectomy, your surgeon will also create an alternative way for urine to leave your body. This is known as urinary diversion.

After surgery many men will be unable to get or maintain an erection (erectile dysfunction). This is because the operation can damage the nerves responsible for getting an erection. However, treatments for erectile dysfunction are usually available.

See the complications of bladder cancer surgery for more information about urinary diversion and sexual problems after surgery.

Radiotherapy

Radiotherapy uses pulses of radiation to destroy cancerous cells and is an alternative treatment option for muscle-invasive bladder cancer.

Radiotherapy can be used:

• as a primary treatment to try to cure bladder cancer – this may be a preferred option if your general health is thought to be too poor to withstand the effects of surgery
• to help control the symptoms in cases of incurable bladder cancer – known as palliative radiotherapy

External radiotherapy

Radiotherapy used to shrink tumours and achieve a cure is given by a machine that beams the radiation at the bladder (external radiotherapy).

Sessions of external radiotherapy for bladder cancer are usually given on a daily basis for five days a week over the course of four to seven weeks. Each session lasts for about 10 to 15 minutes.

As well as destroying cancerous cells, radiotherapy can also damage healthy cells, which means it can cause a number of side effects. These include:

• diarrhoea
• inflammation of the bladder (cystitis)
• tightening of the vagina (in women), which can make having sex painful
• erectile dysfunction (in men)
• loss of pubic hair
• infertility
• tiredness
• incontinence

Most of these side effects should pass a few weeks after your treatment finishes, although there is a chance they will be permanent.

The fact that radiation has been directed at your pelvis will usually mean that you will be infertile for the rest of your life. This is not a problem for most people who undergo radiotherapy, as they are too old to have children by the time they have treatment.

Palliative radiotherapy

Palliative radiotherapy – where the aim is to relieve symptoms – is usually only given for short periods, so it will not usually cause side effects. If there are side effects, they will only last for a short time.

However, it can take time for palliative radiotherapy to be effective, so you might feel worse before you start feeling better.

Read more about radiotherapy.

Surgery or radiotherapy?

Your MDT may recommend a specific treatment because of your individual circumstances.

For example, someone with a small bladder or many existing urinary symptoms is better suited to surgery. Someone who has a single bladder tumour with normal bladder function is better suited for treatments that preserve the bladder.

However, your input is also important, so you should discuss which treatment is best for you with your MDT.

There are pros and cons of both surgery and radiotherapy.

The pros of having a radical cystectomy include:

• treatment is carried out in one go
• you will not need regular cystoscopies after treatment, although other less invasive tests may be needed

The cons of having a radical cystectomy include:

• it can take up to three months to fully recover
• there is a risk of general surgical complications, such as pain, infection and bleeding
• there is a risk of complications from the use of general anaesthetic
• an alternative way of passing urine out of your body will need to be created, which may involve an external bag
• there is a high risk of erectile dysfunction in men (estimated at around 90%) as a result of nerve damage
• after surgery some women may find sex uncomfortable, as their vagina may be smaller
• there is a small chance of a fatal complication, such as a heart attack, stroke or deep vein thrombosis (DVT)

The pros of having radiotherapy include:

• there is no need to have surgery, which is often an important consideration for people who are in poor health
• your bladder function may not be affected, as your bladder is not removed
• there is less chance of causing erectile dysfunction (around 30%)

The cons of having radiotherapy include:

• you will require regular sessions of radiotherapy for four to seven weeks
• short-term side effects are common, such as diarrhoea, tiredness and inflammation of the bladder (cystitis)
• there is a small chance that the bladder could be permanently damaged, which could lead to urinary incontinence
• women may experience a narrowed vagina, making sex difficult and uncomfortable

Chemotherapy

In some cases chemotherapy may be used to treat muscle-invasive bladder cancer.

However, this is different from the intravesical chemotherapy used to treat non-muscle-invasive bladder cancer. Instead of medication being put directly into your bladder, it is put into a vein in your arm.

This is called intravenous chemotherapy and can be used:

• before radiotherapy and surgery to shrink the size of any tumours
• in combination with radiotherapy before surgery (chemoradiation)
• to slow the spread of incurable advanced bladder cancer (palliative chemotherapy)

As yet there is not enough evidence to say whether chemotherapy is an effective treatment when it is given after surgery to prevent the cancer returning, so it usually only used this way as part of a clinical trial. See clinical trials for bladder cancer for more information.

Chemotherapy is usually given over a few consecutive days at first. You will then have a few weeks off to allow your body to recover before the treatment begins again. This cycle will be repeated for a few months.

As the chemotherapy medication is being injected into your blood, you will experience a wider range of side effects than if you were having intravesical chemotherapy. These side effects should stop after the treatment has finished.

Chemotherapy weakens your immune system, making you more vulnerable to infection. It is therefore important to report any symptoms of a potential infection, such as a high temperature, persistent cough or reddening of the skin, to your MDT. Avoid close contact with people who are known to have an infection.

Other side effects of chemotherapy can include:

• nausea
• vomiting
• hair loss
• lack of appetite
• tiredness

Read more about chemotherapy. 

Follow-up

If your treatment did not involve removing your bladder, there is a risk that the cancer will return.

The risk of bladder cancer returning after treatment is generally higher in cases of superficial bladder cancer compared to muscle-invasive bladder cancer, and can be as high as 80% in some cases of particularly high risk superficial bladder cancer.

Your risk is also increased if you have:

• multiple tumours
• a tumour(s) larger than 3cm (one inch) in diameter
• a previous history of recurring bladder cancer

It is therefore recommended that you attend regular follow-up appointments so you can be monitored.

Your MDT will be able to provide more advice and recommendations regarding the timing of your follow-ups.