How is bladder cancer diagnosed?

An ultrasound uses soundwaves to create a picture of the bladder. This scan is used to show if cancer is present and how large it is, but an ultrasound can’t always find small tumours.

Your medical team will usually ask you to drink lots of water before the ultrasound so you have a full bladder. This makes the bladder easier to see on the scan. After the first scan, you will go to the toilet and empty your bladder, then the scan will be repeated.

During an ultrasound, you will lie on a bench and uncover your abdomen (belly). A cool gel will be spread on your skin, and a small handheld device called a transducer will be moved across your abdominal area. The transducer creates soundwaves that echo when they meet something solid, such as an organ or tumour. A computer turns the soundwaves into a picture. An ultrasound scan is painless and usually takes 15–20 minutes.

In many cases, the next test will be a cystoscopy. This will be done with a flexible cystoscope – a thin, bendy tube with a light and a camera on one end. This procedure is done under local anaesthetic, with a gel squeezed through a thin tube into the urethra to numb the area. The cystoscope is put in through your urethra and into the bladder. The camera projects images onto a monitor so the doctor can see inside the bladder.

A flexible cystoscopy usually takes only a few minutes. For a few days afterwards, you may see some blood in your urine and feel mild discomfort when urinating.

If the ultrasound and flexible cystoscopy suggest there are areas in the bladder that look like cancer, you will probably have a cystoscopy with a rigid cystoscope (a thin tube that does not bend). This is done in hospital under general anaesthetic, usually as a day procedure.

The doctor may insert some instruments through the rigid cystoscope and remove tissue samples or small tumours from the lining of the bladder. This is known as a biopsy. A specialist doctor called a pathologist will examine the tissue under a microscope for signs of cancer. Biopsy results are usually available in 5–7 days. If you feel anxious waiting for the results, call Cancer Council 13 11 20 for support.

A rigid cystoscopy takes about 30 minutes. After the procedure, you may have some urinary symptoms, such as going to the toilet frequently, needing to rush to the toilet, or even having trouble controlling your bladder (incontinence). These symptoms will usually settle in a few hours. Keep drinking fluids and stay near a toilet.

For a few days afterwards, you may also have some discomfort or notice some blood in your urine. Avoid lifting heavy objects until any bleeding has settled.

After a rigid cystoscopy, you may need a urinary catheter for a few hours or up to 1–2 days. If larger tumours need to be removed during a cystoscopy, the operation is called a transurethral resection of bladder tumour (TURBT).

A CT (computerised tomography) scan uses x-rays and a computer to create a detailed picture of the inside of the body.

A scan of the urinary system may be called a CT urogram, CT IVP (intravenous pyelogram) or a triple-phase abdomen and pelvis CT – these are different names for the same test. Some people have a CT scan of other areas of the body to see if the cancer has spread.

CT scans are usually done at a hospital or a radiology clinic. When you make the appointment for the scan, you will be given instructions to follow about what you can eat and drink before the scan.

As part of the procedure, a dye (the contrast) is injected into one of your veins. The dye travels through your bloodstream to the kidneys, ureters and bladder, and helps show up abnormal areas more clearly.

The scan is usually done three times: once before the dye is injected, once immediately afterwards, and then again a bit later. The dye may make you feel hot all over and cause some discomfort in the abdomen. Symptoms should ease quickly, but tell the person doing the scan if you feel unwell.

During the scan, you will need to lie still on a table that moves in and out of the scanner, which is large and round like a doughnut. The whole procedure takes 30–45 minutes.

Before having scans, tell the doctor if you have any allergies or have had a reaction to contrast (dye) during previous scans. You should also let them know if you have diabetes or kidney disease or are pregnant or breastfeeding.

Less commonly, your doctors may recommend an MRI (magnetic resonance imaging) scan to check for bladder cancer. This scan uses a powerful magnet and radio waves to create detailed cross-sectional pictures of organs in your abdomen.

Before the scan, let your medical team know if you have a pacemaker or any other metallic object in your body. If you do, you may not be able to have an MRI scan, although some newer devices are safe to go into the scanner. Also ask what the MRI will cost, as Medicare usually does not cover this scan for bladder cancer.

Before the MRI, you may be injected with a dye to help make the pictures clearer. You will then lie on an examination table inside a large metal tube that is open at both ends. The person doing the scan (radiographer) will place you in a position that will allow you to stay still and limit movement during the MRI.

You will hear loud repetitive sounds during the scan. The test is painless, but the noisy, narrow machine makes some people feel anxious or claustrophobic. If you think you could become distressed, mention it beforehand to your medical team. You may be given a mild sedative to help you relax or you might be able to bring someone into the room with you for support. You will usually be offered earplugs, or headphones to listen to music. The MRI scan takes between 30 and 90 minutes.

Before having scans, tell the doctor if you have any allergies or have had a reaction to contrast (dye) during previous scans. You should also let them know if you have diabetes or kidney disease or are pregnant or breastfeeding.

A CT or MRI scan can sometimes show if and how far the bladder cancer has spread, but you might also need other imaging tests such as a radioisotope bone scan, x-rays or a PET–CT scan.

Radioisotope bone scan

You may have a radioisotope scan to see whether the cancer has spread to the bones. It may also be called a whole-body bone scan (WBBS) or simply a bone scan.

Before you have the scan, a tiny amount of radioactive dye is injected into a vein, usually in your arm. You will need to wait for a few hours while the dye moves through your bloodstream to your bones. The dye collects in areas of abnormal bone growth. Your body will be scanned with a machine that detects radioactivity. A larger amount of radioactivity will show up in any areas of bone affected by cancer cells.

The scan is painless. After the scan, you need to drink plenty of fluids to help remove the radioactive substance from your body through your urine. It usually passes out of the body in a few hours. You should avoid being around young children and pregnant women for the rest of the day. Your treatment team will discuss these precautions with you.

X-rays

You may need x-rays if a particular area looks abnormal in other tests or is causing symptoms. A chest x-ray can check the health of your lungs and look for signs the cancer has spread. Sometimes, people will have a CT scan instead of an x-ray.

PET-CT scan

A PET (positron emission tomography) scan combined with a CT scan is a specialised imaging test. It can sometimes be used to find bladder cancer that has spread to lymph nodes or other areas of the body that may not be picked up on a CT scan. Ask what the scan will cost, as Medicare does not currently cover the cost of a PET–CT scan for bladder cancer.

Clinic staff will tell you how to prepare for a PET–CT scan, particularly if you have diabetes. Before the scan, you will be injected with a glucose solution containing a small amount of radioactive material. Cancer cells show up brighter on the scan because they take up more glucose solution than normal cells do. You will be asked to sit quietly for 30–90 minutes as the glucose moves through your body, then you will be scanned. It will take several hours to prepare for and have the PET–CT scan.