Bladder Cancer:
Painless Blood in the Urine, Treatment & Follow-Up Care

1. What is bladder cancer?

Bladder cancer is a malignant tumour that starts in the inner lining of the bladder. This lining is called the urothelium; it also lines the renal pelvis, the ureters and the urethra. That is why by far the most common type is urothelial carcinoma. Bladder cancer mainly affects older people, and men develop it several times more often than women.^¹,²

The typical first sign is blood in the urine that does not hurt. Because it often disappears on its own after a few days, it is easily dismissed. That is exactly what this article is about: painless does not mean harmless. How to make sense of reddish urine in general — from beetroot to kidney stones — is explained in the symptom article Blood in urine. Here the focus is on the disease itself: diagnosis, treatment and life afterwards.

2. Types and stages

For treatment and prognosis, one question matters above all: has the tumour grown into the muscle layer of the bladder wall or not?^³

In addition, the pathologist assesses the grade: “low grade” grows slowly and often comes back but rarely progresses; “high grade” is more aggressive. Stage, grade, size, the number of tumours and whether CIS is present together give a risk group (low, intermediate, high, very high), which determines follow-up treatment and the intervals between check-ups.^³,⁴ Rare types such as squamous cell carcinoma or adenocarcinoma of the bladder are sometimes treated differently.

3. Symptoms: blood in the urine and other signs

• Visible blood in the urine (macroscopic haematuria) — red, pink, brownish or with clots, usually without pain. It often appears only once or comes and goes.
• Invisible blood (microscopic haematuria) — only shows up on a urine dipstick test or under the microscope.
• Irritable bladder symptoms — more frequent urge to pass urine, burning when urinating, small amounts of urine. Typical above all of carcinoma in situ.
• Signs of advanced stages — flank pain caused by a blocked ureter, bone pain, unintended weight loss, swollen legs.

Most of these symptoms have more harmless causes. The following table shows how common triggers differ — but it does not replace a medical assessment.^¹

Conversely, some medicines colour the urine without any blood being present: for example nitrofurantoin (yellow-brown), metronidazole and levodopa (dark) or the tuberculosis medicine rifampicin (orange-red). A dipstick test at the practice quickly tells the difference.

4. Causes and risk factors

The kidneys excrete many harmful substances in the urine, which then sits in the bladder for hours. Cancer-causing substances therefore act directly on the lining. The most important risk factors:^¹,³

• Smoking — by far the most important factor. Smokers have a risk several times higher, and a large share of all bladder cancer cases can be traced back to tobacco. After stopping smoking, the risk falls again over the years.
• Aromatic amines at work — in the past mainly in the dye, rubber, leather and textile industries, and also among painters or hairdressers with many years of contact with certain dyes. Bladder cancer caused by aromatic amines is recognised as an occupational disease in Germany (occupational disease no. 1301), often decades after the exposure.^⁵
• Age and sex — the risk rises markedly with age, and men are affected more often.
• Previous radiotherapy to the pelvis — for example for prostate or womb cancer.
• Chronic bladder inflammation — for example with a long-term catheter or with schistosomiasis (bilharzia), a tropical disease that is rare in Germany; above all, it favours squamous cell carcinomas.

In women, bladder cancer is on average discovered later, because blood in the urine is often first put down to cystitis or to their period. A “bladder infection” that does not clear up despite an antibiotic, or keeps coming back without any bacteria being found, therefore needs to be investigated more closely.^¹

5. Diagnosis: from urine sample to cystoscopy

According to the guideline, any visible bleeding in the urine should be investigated by a urologist. Invisible blood is investigated depending on age and risk profile. There is no general screening for bladder cancer.^³

• Urine test: dipstick, microscopy and, if necessary, a urine culture to rule out an infection.
• Ultrasound: of the bladder and kidneys, painless — but it misses small or flat tumours.
• Cystoscopy: the decisive examination. A thin, flexible endoscope is passed through the urethra with anaesthetic gel; usually done as an outpatient in a few minutes.
• Urine cytology: a search for tumour cells in the urine — helpful above all for aggressive and flat tumours.
• TURBT: if something is found, the tumour is removed through the urethra under anaesthetic (transurethral resection). This is diagnosis and first treatment at the same time. For T1 or high-grade tumours, a second resection often follows a few weeks later.
• Imaging: a CT scan with contrast (CT urography) checks the kidneys and ureters; with a muscle-invasive tumour, the chest and abdomen are also checked for secondary tumours.

To put it honestly: urine tests for so-called tumour markers are sometimes offered as self-pay services. According to the guideline, they cannot replace cystoscopy and are not suitable for early detection in people without symptoms.^³ Before the TURBT, the team will discuss whether and when blood thinners are paused — that is for the treatment team to decide; see also Medications before surgery. For the first consultation, the guide Preparing for a doctor’s appointment will help.

6. Treatment of non-muscle-invasive bladder cancer

Around three quarters of bladder tumours are discovered at this stage. Treatment has two aims: to remove the tumour completely, and to prevent relapses and progression into the muscle layer. Which steps follow the TURBT depends on the risk group.^³,⁴

To put it honestly: even with the best treatment, non-muscle-invasive tumours often come back — usually superficial again and readily treatable. That is why years of follow-up with cystoscopies are not a sign of mistrust but part of the treatment. Which option suits you is decided by the treatment team together with you; a second opinion before removal of the bladder is expressly your right.^³

7. Muscle-invasive bladder cancer: surgery, chemo, bladder preservation

If the tumour has grown into the muscle layer, removal through the urethra is no longer enough. Treatment belongs in an experienced centre and is planned at a tumour board.^³

8. Medicines, side effects and interactions

Depending on the stage, instillations, infusions, immunotherapy and many supportive medicines come together. What matters most:^⁷

• BCG and antibiotics: according to the Summary of Product Characteristics, BCG bacteria are sensitive to certain antibiotics, for example fluoroquinolones such as ciprofloxacin, doxycycline or gentamicin. Always check any new antibiotic with the urology team during the BCG phase. If you have an acute urinary tract infection, the instillation is postponed.
• BCG and the immune system: if you take immunosuppressants, higher-dose cortisone or biologics, you may not be able to have BCG — disclose all your long-term medicines beforehand. For vaccinations around the time of treatment, see Vaccines and medications.
• Cisplatin: can damage the kidneys, hearing and nerves; as a precaution you are given plenty of fluids and anti-sickness medicines, for example ondansetron — on a fixed schedule, not only once symptoms appear. Painkillers such as ibuprofen or diclofenac put additional strain on the kidneys.
• Enfortumab vedotin: typical effects are skin reactions, tingling in the hands and feet (polyneuropathy), dry eyes and raised blood sugar levels — with diabetes, your levels are monitored more closely.
• Immune checkpoint inhibitors: can trigger inflammation in almost any organ, for example the thyroid, bowel, lungs or skin — even weeks after the last dose.

Interactions are hard to keep track of with cancer treatments, especially as many of those affected are older and already take several long-term medicines. So always raise St John’s wort, high-dose supplements and any new over-the-counter preparations beforehand; the guide Drug interactions is a good place to start. The choice and dose of every medicine is decided by the treatment team.

9. Living with a urostomy or neobladder

After removal of the bladder, urine needs a new route out. Which urinary diversion is an option depends on the extent of the tumour, kidney function, age and your own wishes. A thorough consultation before the operation, including with a stoma nurse, is important.^³

• Train the neobladder — at first, empty it by the clock, at night too with an alarm, and slowly lengthen the intervals. Wetting at night is common in the first few months and often improves.
• Monitor your metabolism — the bowel lining in the replacement bladder absorbs salts from the urine. Over-acidification of the blood is detected with blood gas tests and sometimes corrected with sodium bicarbonate.
• Think about vitamin B12 — if the end of the small intestine is missing, vitamin B12 deficiency can develop over the years. Regular checks are part of follow-up care.
• Keep an eye on your kidneys — narrowing of the ureters or recurrent infections can put a strain on the kidneys; see chronic kidney disease.
• Talk about sex — after the operation, erection problems are common in men, and pain during intercourse in women. Help is available; more under erectile dysfunction.

10. Follow-up care and everyday life

Follow-up care depends on the risk group. With non-muscle-invasive bladder cancer, cystoscopies are at the centre — every few months in the first years, less often later, and for life if the risk is high. After a cystectomy, imaging, kidney function and blood tests are added.^³,⁴

• Stopping smoking is worth it now too — smoking is associated with more frequent relapses. Medical support, nicotine replacement or stop-smoking programmes markedly increase the chances of success compared with quitting on your own.
• Always report blood in the urine — between two check-ups as well. After a TURBT a little blood is normal for a few days; clots or being unable to pass urine are not.
• Have an occupational disease checked — if you had contact with dyes, rubber or tar products at work, the practice can report a suspected occupational disease. This can lead to financial benefits.
• Drink enough — sensible for the kidneys and a replacement bladder. However, there is no evidence that drinking a lot prevents relapses.
• Accept support — inpatient rehabilitation after hospital, stoma care, continence training, psycho-oncological counselling and self-help groups are all part of care.

Many people with bladder cancer are older and already take medicines for high blood pressure, diabetes or heart rhythm disorders. Over the years, check-ups, instillations and new medicines are added. An up-to-date medication plan and a list of all appointments are then not bureaucracy but safety.

Instillations, check-ups, medicines — under control with brite

Dose reminders, interaction checks, your results over time. Free.

Get started now