The bladder is a hollow, muscular, balloon-like organ that sits inside the pelvis and stores urine. Urine consists of water and waste products that are not needed by the body. The bladder is lined with a membrane that stops the urine going into the body called ‘urothelium’.

Bladder Cancer

Bladder cancer is twice as common in men as women, and is rare is people under 55 years of age. Cigarette smoking is the most common risk factor, but exposure to workplace dyes and chemicals is also a risk. Previous radiation treatment for other tumours and the use of cyclophosphamide chemotherapy increase the risk of developing bladder cancer.

In Australia, most bladder tumours are Urothelial Carcinomas (previously called Transitional Cell Carcinomas). Much less commonly, Squamous Cell Carcinomas (SCCs) or adenocarcinomas can occur.

Diagnosis:

The most common symptom of bladder cancer is passing blood in the urine (haematuria). Other symptoms include needing to pass urine frequently or painful urination when no infection is present. Blood in the urine should always be investigated to rule out bladder cancer.

Your GP will usually organize an ultrasound and a series of urine tests (to exclude an infection and check for atypical cells). Your urologist will arrange for a CT scan with contrast (dye injected into the vein) to assess the kidneys, ureter and bladder lining. They will then arrange for a flexible cystoscopy, a telescope inspection of the bladder to check the bladder lining.

If the initial imaging shows an abnormality in the bladder or an irregularity is identified at the flexible cystoscopy further treatment will be arranged.

Treatment:

Flexible Cystoscopy: A fine, flexible telescope is passed through the urethra (water pipe) into the bladder. This is a quick procedure, taking only a few minutes. It can be performed with either local anaesthetic gel or sedation, depending on the patient’s preference.

Cystoscopy and Bladder Biopsy: A cystoscope (telescope) is passed into the bladder through the urethra. If a small irregular area is identified a biopsy can be taken. Cautery is then used to stop any bleeding. This can usually be done as a day case.

TURBT (Trans-Urethral Resection of Bladder Tumour): If a larger lesion is identified in the bladder a cautery loop can be used shave the tumour from the inside of the bladder. The abnormal tissue is then flushed out of the bladder via the telescope and sent to the Pathology lab for analysis. A catheter is placed at the end of the procedure and irrigation of the bladder is commenced to stop blood clots forming in the bladder. This catheter can usually be removed early the next morning.

Further treatment will depend on the results of the analysis of the removed tissue.

Superficial bladder cancer involves only the innermost layer of the bladder lining. These tumours can be completely removed with a biopsy or TURBT.

Depending on the grade of the tumour, your Urologist may recommend additional treatment to minimize the chance to having future tumours. Either chemotherapy or an immunotherapy called BCG can be instilled into the bladder through a catheter to reduce the risk of recurrence.

Superficial bladder cancers tend to recur every few years. Anyone diagnosed with superficial bladder cancer will need regular check-up cystoscopies, so recurrences can be detected early and treated at an early stage.

Muscle invasive bladder cancer is cancer that has invaded into the deeper muscle layer of the bladder. These cancers are more serious and require more aggressive treatment. The most effective treatment is surgery to remove the entire bladder. In most cases a short course of chemotherapy is arranged prior to surgery.

In patients who are not well enough for major surgery or who elect not to have an operation, a combination of chemotherapy and radiation treatment can be used.

Open or Robotic Radical Cystectomy and Cystoprostatectomy: This operation to remove the entire bladder (and prostate in men) along with the lymph nodes of the pelvis is considered the gold standard treatment for muscle invasive bladder cancer. Once the bladder has been removed an alternative drainage system for urine is required. The urinary tract is reconstructed by taking a small piece of bowel to create a conduit (attached to a stoma on the abdominal wall) or to fashion a new bladder (neobladder).

Benign bladder conditions

Recurrent bladder infections (cystitis, urinary tract infections (UTIs)

In women:

UTIs are very common in women; roughly half of the female population will experience a UTI at some stage in their life. Infections are very common in young, sexually active women and post-menopausal women. Typical symptoms include burning or stinging when passing urine, the constant need to pass small volumes of urine and smelly, cloudy or blood-stained urine. Symptoms are usually short-lived or resolve with a short course of antibiotics, but cause problems when they become frequent or recur shortly after ceasing antibiotics. It is also possible for a bladder infection to spread upwards to the kidneys, which is a more serious infection.

Treatment for infections:

When you first get symptoms of an infection –

1. Increase your water or fluid intake. Avoid caffeinated drinks that act as a diuretic and cause dehydration.
2. See you GP to send a urine specimen and consider commencing antibiotics.
3. Consider using “Ural” sachets to reduce the acid content of the urine, which may ease the stinging sensation.
4. Simple pain relief such as paracetamol or ibuprofen may ease your symptoms.
5. If you develop flank pain or fevers you should see your GP.

Strategies to minimize infections:

1. Maintain a high fluid intake (water or clear fluids); aim for 2 litres per day.
2. Always pass urine after sexual intercourse.
3. Take a cranberry supplement (or cranberry juice).
4. In post-menopausal women a topical oestrogen cream to maintain the condition of the vaginal mucosa is often helpful.
5. Others options that may be considered
   1. on demand antibiotics (to take after sexual activity or at the first sign of an infection)
   2. long term, low dose antibiotics
   3. urine antiseptics such as Hiprex.

When to see a Urologist:

If you are having very frequent infections, infections that recur shortly after ceasing antibiotics, infections that are difficult to clear or you have previously had surgery on the urinary tract, you may have an infection that requires specialist input. In these cases excluding a structural cause for your infections is important.

In men:

Bladder infections in men are much less common than infections in women, largely because the male urethra (water pipe) is longer than in femaies. Infections in men become more common with increased age. A single infection is usually nothing to worry about, but repeated infections may indicate an underlying problem, such a poor bladder emptying due to prostatic enlargement or poor bladder function.