Diagnosing Bladder Cancer

Medical oncologists, imaging specialists, and urologic pathologists at NYU Langone’s Laura and Isaac Perlmutter Cancer Center work together to diagnose bladder cancer.

The bladder, which is part of the body’s urinary system, is a hollow, muscular organ that collects and stores urine. It releases urine into the urethra, the membranous tube that carries the urine to the outside of the body.

The cells that line the inside of the urinary system are called urothelial cells or transitional cells. Because most of the cancers that arise from the urothelial cells occur in the bladder, urothelial cancer is a term often used interchangeably with bladder cancer.

Urothelial cancers that haven’t spread to the connective tissue or muscle that make up the organ’s walls are the earliest forms of bladder cancer. Tumors that grow into the bladder walls or spread to other organs are considered more advanced.

Urothelial cells also line the upper urinary tract, which includes the renal pelvis and ureters, which are tubes that connect and carry urine from the kidneys to the bladder. Cancer that arises from urothelial cells of the upper urinary tract is called upper urinary tract cancer and is very similar to bladder cancer. However, treatment approaches are somewhat different.

Bladder cancers involving other types of cells in the organ are more rare. These include squamous cell carcinoma, which involves flat cells that can be found in the lining of organs, as well as adenocarcinoma, which forms in gland cells that secrete mucus. Small cell carcinoma, which begins in cells that receive nerve impulses and produce hormones, can also occur.

These forms of cancer tend to be aggressive. Often, they have spread to tissue beyond the bladder by the time they’re diagnosed.

Risk Factors

One of the leading risk factors for bladder cancer is smoking. Our physicians strongly urge smokers to quit. If you need help, NYU Langone offers comprehensive assistance through its Tobacco Cessation Programs.

Environmental exposure to some dyes and chemicals also increases the risk of bladder cancer. For example, chemicals used in the rubber and leather industries and those used by hairdressers, painters, and textile workers have been linked to bladder cancer. Firefighters have an increased risk as a result of smoke inhalation.

Generally, the incidence of bladder cancer is higher in men and in elderly people. The most common symptom of bladder cancer is blood in the urine, visible either to the naked eye or under a microscope during routine urine tests. People with the condition may also experience pain during urination, pain in the side or lower back, and a frequent urge to urinate.

To diagnose the condition, your NYU Langone doctor may ask about your symptoms and medical history, perform a physical exam, and request a series of tests.

Urine Cytology

To help diagnose bladder cancer, NYU Langone specialists can directly evaluate bladder cells found in the urine using a microscope.

Urologic pathologists—doctors who study diseases of the urinary system in a laboratory—stain the cells with dyes that highlight cellular abnormalities associated with bladder cancer. Then they study these patterns under a microscope to determine whether cancer is present.

Flexible Cystoscopy and Biopsy

During a flexible cystoscopy, the doctor applies a local anesthetic and then inserts a cystoscope, a small flexible tube containing a tiny, lighted video camera on the end, into the urethra. He or she guides the cystoscope into the bladder to view the organ’s inner lining.

If the doctor sees unusual tissue or growths, a biopsy is performed. During a biopsy, tissue is removed for examination under a microscope, so that the doctor can determine whether cancer is present. Cystoscopy can cause minor irritation of the bladder, which may result in some bleeding shortly afterward.

Transurethral Resection

When doctors need a more extensive biopsy to determine the aggressiveness of a cancerous tumor, they may use a procedure called transurethral resection. During this procedure, which usually requires general anesthesia, the doctor performs a cystoscopy using a larger, more rigid cystoscope. He or she then inserts a flexible instrument called a resectoscope through the cystoscope.

The resectoscope has a wire loop at the end that is used to remove the whole tumor or a portion of it. The doctor also samples a portion of the bladder muscle underneath the tumor to see whether cancerous cells have spread into the muscle.

Doctors at NYU Langone have access to a new technology called blue light cystoscopy, which may help them to detect and remove more tumors, allowing for a more complete transurethral resection. For this procedure, they inject a light sensitive contrast solution into the bladder through a catheter, or hollow tube, placed in the urethra.

Doctors wait about an hour for this solution to accumulate in bladder cancer cells. They then place a cystoscope with a special blue light on the end into the bladder. The contrast solution makes cancer cells appear pink or red under this blue light.

A urologic pathologist examines the tissue under a microscope and performs other tests to determine the type of cancer and how advanced and aggressive it is.

If the doctor is able to remove the entire tumor during transurethral resection, the procedure may also serve as the only required treatment for bladder cancer, depending on the findings of the urologic pathologist.

People may experience minor bleeding through the urethra or minor discomfort in the pelvic area where the bladder is located for a few days or weeks after the procedure.

CT Scans

A doctor may order a CT scan. This test uses X-rays and a computer to create three-dimensional, cross-sectional pictures of the bladder, as well as the ureters and kidneys.

A CT scan may be used to see whether bladder cancer has invaded the bladder wall or has spread to other organs or nearby lymph nodes. Lymph nodes are small immune system glands that are often the first place cancer spreads, causing them to enlarge.

Before the scan, your doctor may ask you to drink a liquid contrast agent or have a contrast dye injected into a vein to enhance the ability to see cancerous cells on the CT images.

MRI Scans

If a CT scan can’t be performed or doesn’t provide sufficient imaging of the bladder, doctors may order an MRI scan. MRI uses a magnetic field and radio waves to create computerized, three-dimensional images of organs, soft tissues, and bone in your body.

The results of this test may give your doctor more information about your tumor and enable him or her to determine whether cancer involves other organs in the urinary system or has spread to other parts of the body. Prior to the scan, the technician who conducts the test may inject a contrast dye into a vein to enhance the images.

PET/CT Scans

If doctors need more detailed images of the bladder and surrounding organs to see if the cancer has spread, they may use a combined PET/CT scan to evaluate them. Whereas the CT portion of the scan uses X-rays to create computerized, cross-sectional images of the body, the PET scan detects how active a tumor is and whether it is more likely to be cancerous.

The PET scan detects activity in a tumor using a small amount of radioactive glucose, or sugar, which is injected into a vein. This material collects in cancer tissue and can be seen with a special camera.


Your doctor may recommend another combined imaging technique, called PET/MRI. NYU Langone physicians were the first to show that this new technology may improve doctors’ ability to determine if and how far bladder cancer has spread.

This approach may also be used after treatment to determine whether bladder cancer has responded to treatment.

Next Steps

Based on your test results, NYU Langone physicians create a customized treatment plan for you. If you have early cancer, meaning it is not invading the bladder muscle or other organs, the goal is to remove the tumor and preserve the bladder. More advanced cancers may require more extensive surgery, chemotherapy, and, possibly, radiation therapy.

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