There are a number of tests that check for the possibility of bladder cancer and the grade and stage of the condition. These tests help the doctors, your specialist and nurses to consider the most appropriate treatment.
The usual first step is that your GP will discuss your general health, ask about symptoms and do a general examination. They may do a urine test at the surgery or send a sample to the lab. Then if necessary, a specialist, often the urologist, will conduct further tests. See Who's Who for a list of the people you are most likely to see during your treatment.
One of the warning signs for bladder cancer is visible blood in the urine (visible haematuria). Unless there is another clear cause for the blood (e.g. confirmed urinary infection), people should be referred by their GP for further tests immediately under a policy of being seen by a urologist within two weeks of referral - the 2 week rule (as is now set out in the NICE guidelines for suspected cancer). This urgent referral particularly applies to people over the age of 45, but unexplained visible blood in the urine, at whatever age, requires further investigation.
When traces of blood aren't actually visible but are only picked up on testing this is known as non-visible haematuria and similarly warrants prompt further testing in people over the age of 40 yrs. In patients under the age of 40, non-visible haematuria in the absence of any other symptoms is very rarely due to bladder cancer. The blood is usually a result of ‘leaky kidneys' and is rarely of any consequence - however, there is a small link with kidney problems in later life, and persistent non-visible haematuria should be monitored by your GP surgery with an annual blood, urine and blood pressure test - to act as an early warning system if kidney problems should develop.
You should be aware that there are several types of disorders which might cause blood in the urine including: cancers (of the bladder, prostate, kidney); urinary tract stones (kidney and urinary bladder); infections; non-cancerous swelling of the prostate gland in men. Additionally, problems with kidney function can allow blood to pass into the urine. For most people, however, no serious problem is found.
The majority of people who have blood in their urine do not have bladder cancer. Of those referred to a hospital ‘haematuria clinic', around 25% of people with visible blood in their urine will have bladder cancer identified. This means that 75% will not - but there may be other causes for the blood. For non-visible haematuria the figure is much lower, less than 5%.
It is therefore vital that you seek advice from your doctor to find the cause and have it treated appropriately.
THE HAEMATURIA CLINIC
When you are referred by your GP with these symptoms, you may be given an appointment at a haematuria clinic (many hospitals have these clinics, or sometimes these can take place in GP surgeries). At the clinic, these symptoms can be investigated and people can be reassured or informed of their diagnosis and treatment straight away.
A doctor or nurse will ask questions about your urinary symptoms, general health, previous medical history, medications, family history, occupation and smoking history. These questions help build up a picture of what might be causing the bleeding. A physical examination will be performed and this may include a rectal examination for men and a vaginal examination for women.
A mid-stream urine sample will be taken and sent to the lab to check for urinary infection. Additionally, urine may be sent for cytology, which is checking for cancerous cells under the microscope. Urine cytology does not pick up every cancer, and not every abnormal cytology sample indicates cancer is present. Other tests are needed to confirm the diagnosis - these are listed in Scans and Tests.
If a bladder tumour is seen on ultrasound scan or flexible cystoscopy this will be explained to you and any family members with you. A specialist nurse is usually available to offer support and information. Arrangements will be made for a hospital admission within a few weeks for a procedure under general anaesthetic to remove or biopsy the tumour.
If other disorders are suspected such as stones, swelling of the prostate or kidney impairment then treatment will be commenced or arranged with the appropriate specialist. For many patients however, no cause will be identified for the blood in the urine, but advice should be given about what to do if blood is seen or detected again in the future.
SCANS AND TESTS
A scan of the urinary tract will be undertaken as part of the Haematuria Clinic process. Scans help the urologist to assess to what extent, if at all, the cancer has spread. These could be ultrasound (using sound waves to show images inside your body), MRI (Magnetic Resonance Imaging) or CT (Computed Tomography) scans. For most people it will be an ultrasound scan - which is a painless and commonly used test. Some patients may subsequently be referred for a CT scan depending on the results of other tests.
Intravenous Urogram or IVU
IVU is a test to look for anything unusual in the urinary system. A dye is injected into a vein in the arm. The kidneys work to gradually remove the dye from the bloodstream. The movement of the dye is viewed and assessed on an X-ray screen. In many centres, IVU has now been replaced by CT (Computed Tomography) Urogram. A CT Urogram is often of better quality than one produced with X-ray and it also reduces exposure to radiation.
A telescopic examination of the bladder is almost always required. The urologist uses a fine, fibreoptic telescope with a camera at the end to look inside the bladder for anything unusual - a cystoscope. This test is done via the waterpipe (urethra) using local anaesthetic gel to make things more comfortable. Many people feel anxious about having this test, but it only takes a couple of minutes to perform. Most people are surprised at how quick this examination is. There is a small risk of urinary infection but this occurs in less than 1% of people and can be treated as required with antibiotics.
Involves the urologist inspecting the bladder under general or spinal anaesthesia. The urologist may also take tissue samples (biopsies) from the bladder and, if necessary, growths will be removed. Any tissue samples are then checked to see whether they contain cancer cells and if so, what kind of cells they are.
Often further flexible or rigid cystoscopies are necessary throughout the course of treatment or to monitor the bladder.