Bladder cancer typically begins in the lining of your bladder, the balloon-shaped organ in your pelvic area that stores urine. Some bladder cancer remains confined to the lining, while other cases may invade other areas.

Most people who develop bladder cancer are older adults — more than 90 percent of cases occur in people older than 55, and 50 percent of cases occur in people older than 73. Smoking is the greatest single risk factor for bladder cancer. Exposure to certain toxic chemicals and drugs also makes it more likely you'll develop bladder cancer.

Treating bladder cancer that has spread can be difficult and involve extensive procedures. But if your bladder cancer is detected early — before it has spread beyond the lining of your bladder — you have a better chance of successful treatment with minimal side effects.

Bladder cancer often doesn't produce signs or symptoms in its early stages. The first warning sign is usually blood in your urine (hematuria). The blood may show up on a urine test, or your urine may appear reddish or darker than normal.

This doesn't necessarily mean you have bladder cancer, however. More common conditions — including a urinary tract infection, kidney disease, kidney or bladder stones, and prostate problems — can cause hematuria. These conditions can also cause other symptoms similar to those of bladder cancer. If you develop any of the signs and symptoms below, your doctor can help determine the exact cause:

• Pelvic pain
• Pain during urination
• Frequent urination or feeling you need to urinate without being able to do so
• Slowing of your urinary stream

Your bladder is a muscular, balloon-shaped organ located in your pelvis. It stores urine that your kidneys produce during the process of filtering your blood. Like a balloon, the bladder can get larger or smaller depending on the amount of urine it holds. Urine passes from your kidneys into your bladder through thin tubes called ureters and is eliminated from your body through another narrow tube, the urethra.

How cancer develops
Healthy cells grow and divide in an orderly way. This process is controlled by DNA — the genetic material that contains the instructions for every chemical process in your body. When DNA is damaged, changes occur in these instructions. One result is that cells may begin to grow out of control and eventually form a tumor, a mass of malignant cells.

Most bladder cancers begin in the specialized cells that line the walls of your bladder (transitional cells). The same type of cells occurs in your kidneys, ureters and urethra where they may also give rise to malignant tumors.

Some cancers remain confined to the bladder lining (carcinoma in situ). But other cancers are invasive, growing into or through the bladder wall, and eventually into nearby lymph nodes and adjacent organs. In time, cancer may spread (metastasize) to other organs, including your lungs, liver or bones.

Causes unclear
Just what causes the DNA damage that leads to bladder cancer isn't entirely clear. A very few cases show signs of inherited mutations — bladder cancer running in the family. More often, it appears that bladder-cancer-causing mutations develop during a person's lifetime. DNA damage may occur due to exposure to certain toxic chemicals, such as those found in cigarette smoke.

On the other hand, inherited factors such as how your body metabolizes certain chemicals may play a role. People whose bodies metabolize toxic chemicals quickly may be less susceptible to bladder cancer than are people who metabolize the same chemicals more slowly.

Although scientists aren't sure what causes bladder cancer, they've identified a number of factors that may contribute to its development, either by themselves or in combination with other factors. Because chemicals often exit the body through the bladder, many of these risk factors have to do with chemical exposure.

Having one or more of the risk factors listed below doesn't guarantee you'll develop bladder cancer, only that your risk may be increased. Knowing about these factors may help you make changes that could reduce your risk, such as quitting smoking.

• Smoking. Smoking appears to be the single greatest risk factor for bladder cancer. That's because cancer-causing chemicals (carcinogens) in tobacco can become concentrated in your urine and eventually damage the lining of your bladder. This damage can increase the chances of a cancer-causing genetic mutation. Smokers are at least twice as likely to develop bladder cancer as nonsmokers are. The risk increases with the number of cigarettes smoked a day and the number of years you've smoked.
• Industrial chemicals. Repeated exposure to chemicals used in the manufacture of dyes, rubber, leather, textiles and paint products may increase your risk of developing bladder cancer years later. Smokers who work with toxic chemicals are at an especially high risk of bladder cancer.
• Age. The chance of getting bladder cancer increases as you grow older. The average age at diagnosis is 68 or 69. People younger than 40 rarely get the disease.
• Race. Whites are twice as likely to develop bladder cancer as blacks and Hispanics are. Asians have the lowest rates of the disease.
• Sex. Men are about four times as likely to get bladder cancer as women are.
• Chemotherapy and radiation therapy. Treatment with the anti-cancer drugs cyclophosphamide (Cytoxan) and ifosfamide (Ifex) increases your risk of bladder cancer. Studies of women treated with radiation therapy for cervical cancer have shown an elevated risk for subsequent development of bladder cancer. But the same doesn't appear to be true for men who receive primary radiation therapy for prostate cancer.
• Chronic bladder inflammation. Chronic or repeated urinary infections or inflammations (cystitis), such as may happen with long-term use of a urinary catheter, may increase your risk of a certain type of bladder cancer called squamous cell carcinoma. But doctors don't believe infection or inflammation alone causes cancer. In some parts of the developing world, especially North Africa, a chronic parasitic infection (schistosomiasis) can contribute to squamous cell carcinoma. Both this infection and squamous cell carcinoma are uncommon in the United States.
• Personal or family history. Having bladder cancer once makes it more likely you'll get it again. Tumors may recur in your ureters or urethra as well as in the bladder itself. If one or more of your immediate relatives has a history of bladder cancer, that also may increase your risk, although it's rare for bladder cancer to run in families. A family history of hereditary nonpolyposis colorectal cancer (HNPCC) can increase the risk of cancer in your urinary system.
• Exposure to arsenic. Drinking water containing high levels of arsenic has been associated with bladder cancer. Risk of exposure to arsenic in drinking water usually depends on where you live and the arsenic content standards for your water system.
• Bladder birth defect. Rare birth defects of the bladder may lead to an unusual form of bladder cancer called adenocarcinoma.

If you think you're at risk of bladder cancer, discuss your concerns with your doctor. He or she may be able to suggest ways to reduce your risk.

See your doctor right away if you develop any of the signs or symptoms of bladder cancer, including bloody, painful or frequent urination.

Your doctor will ask you about your medical history and perform a thorough physical exam. This may include an internal examination during which your doctor gently inserts a gloved, lubricated finger into your rectum or vagina. To help diagnose bladder cancer, you may also have one or more of the following tests:

• Urine cytology. A sample of your urine may be analyzed under a microscope to check for cancer cells. Although common, these tests can miss low-grade cancers.
• Cystoscopy. In this procedure, your doctor inserts a narrow tube (cystoscope) through your urethra. The cystoscope has a lens and fiber-optic lighting system, allowing your doctor to see your urethra and bladder. Your doctor can also use the cystoscope to remove a small sample of tissue (biopsy) for analysis in the laboratory.
• Intravenous pyelogram (IVP). This X-ray allows your doctor to see an image of your kidneys and lower urinary tract, including your bladder. You'll receive an injection of a contrast dye through a vein in your arm. Your bloodstream delivers the dye to your kidneys, ureters and bladder. The contrast agent makes it easier for your doctor to see any abnormalities or tumors on a series of X-rays.
• Tumor marker test. Doctors are evaluating several newer methods that may be more accurate than urine cytology, including tests that check a sample of your urine for substances released by tumors (tumor markers). The Food and Drug Administration has approved two tumor marker tests — BTA and NMP22 — that help diagnose recurrent bladder cancer. Both of these tests involve checking a urine sample for proteins associated with bladder tumors. Another marker under investigation is the enzyme telomerase, which is active in malignant cells but inactive in normal cells. These tests are promising, but they're not recommended for routine use until further studies are completed.
• Fluorescence in situ hybridization (FISH). This test for bladder cancer can detect certain chromosomal abnormalities often found in transitional cell cancer, the most common type of bladder cancer. This test may help detect recurrent cancer cells before a tumor becomes visually apparent. This newer test isn't routinely available, and more studies are needed before it can be considered standard.

Staging tests
If you're found to have bladder cancer, you're likely to have tests to help determine whether the cancer has spread (metastasized) — a process known as staging. The stage of cancer helps your doctor determine the best course of treatment and the outlook for your recovery. Staging tests may include one or more of the following:

• Computerized tomography (CT). This is essentially a highly detailed X-ray that allows your doctor to see your bladder in two-dimensional "slices." Split-second computer processing creates these images while a series of thin X-ray beams pass through your body. In most cases, you will have a contrast dye injected into a vein before the test. The dye makes it easier for your doctor to see your organs and to determine if anything abnormal is present that might suggest cancer. Your greatest risk with this procedure is a possible allergic reaction to the dye.
• Magnetic resonance imaging (MRI). Instead of X-rays, this test uses a powerful magnetic field and radio waves to create images of your urinary tract. During the test, you're enclosed in a cylindrical tube that can seem confining to some people. The machine also makes a loud thumping noise. In most cases you'll be given earplugs to help block out the noise. If you're claustrophobic, ask your doctor whether an open scan or some mild sedation may be an option for you.
• Bone scan. This imaging test is used to determine whether cancer has spread to your bones. During the procedure, a small amount of a radioactive substance that collects in bone is injected into a vein in your arm. A special scanner then takes pictures of all your bones. The radioactive substance highlights areas of abnormal bone.
• Chest X-ray. This test may help detect cancer that has spread to your lungs.

How bladder cancer is staged
Bladder cancer is often staged using the numbers 0 to IV. Most newly diagnosed bladder cancers fall into Stage 0 or Stage I.

• Stage 0 cancer. Also called superficial or in situ cancer, this occurs only on the surface of the inner lining of the bladder. Finding cancer at this stage offers the best hope for a full recovery. Stage 0 cancer can often be completely removed while sparing the bladder, but the rate of recurrence is high.
• Stage I cancer. Cancer at this stage occurs in the bladder's inner lining, but hasn't invaded the muscular bladder wall.
• Stage II cancer. At this stage, cancer has invaded the bladder wall.
• Stage III cancer. The cancer cells have spread through the bladder wall to surrounding tissue. They may also have spread to the prostate in men or the uterus or vagina in women.
• Stage IV cancer. By this stage, cancer cells may have spread to the lymph nodes and other organs, such as your lungs, bones or liver.
• Recurrent. This refers to cancer that has returned after having been treated. It may recur in the same place or in another part of your body.

Bladder cancer can lead to anemia, urinary incontinence and a blockage of the ureters that prevents urine from draining normally into your bladder (hydronephrosis). But the most serious complication is the spread of cancer from the bladder to other organs.

Like many people with cancer, you may choose to take an active role in the decisions affecting your medical care. If so, try to learn as much as you can about bladder cancer and the treatment options that exist. As part of this process, you may want to consider getting a second opinion from a bladder cancer specialist, such as a urologist, medical oncologist or urologic oncologist.

In many cases, your primary care doctor may refer you to one or more specialists. You can also get the names of specialists from a nearby hospital or medical school. Or, contact the Cancer Information Service at (800) 4-CANCER, or (800) 422-6237, to find out information about cancer centers and programs supported by the National Cancer Institute.

Ultimately, the best treatment for you will depend on a number of factors, including the type and extent of bladder cancer you have, as well as on your age, overall health and personal preferences. Below are some of the treatment options:

Surgical procedures
Surgical treatments are usually the best option for people with bladder cancer. The most common procedures include:

• Transurethral resection (TUR). This is often used to treat superficial bladder cancer. During TUR, your doctor inserts a cystoscope — an instrument with a special lens and fiber-optic lighting system — into your bladder through your urethra. The cancer is removed with a small wire loop and any remaining cells are burned away with an electric current. In some cases, a high-energy laser may be used instead of the electric current. TUR itself causes few problems. You're likely to have some blood in your urine or pain when you urinate for a few days following the procedure. But because superficial bladder cancer commonly recurs, you'll need to see your doctor for a cystoscopic exam every three to six months.
• Segmental cystectomy. This procedure may be an option when a tumor has invaded just one part of the bladder wall. It removes only the portion of the bladder that contains cancer cells. To remove the tumor, the surgeon makes an incision in your abdomen. General anesthesia is used, and you usually stay in the hospital for a week to 10 days. The main side effect of this surgery is more frequent urination. Although the problem is often temporary, it may become permanent in some people.

• Radical cystectomy. Doctors may use this extensive operation for invasive bladder cancer or for superficial cancer that affects a large portion of the bladder. It involves removing the entire bladder, as well as nearby lymph nodes and part of the urethra. In men, the prostate gland, seminal vesicles — which produce some of the fluid in semen — and a portion of the vas deferens (a conduit for sperm) also are removed. For women, radical cystectomy usually means removing the ovaries, fallopian tubes and part of the vagina.

  After a radical cystectomy, your surgeon may construct a new bladder for you or attach a pouch — either internally or externally — to collect urine.

  Radical cystectomy can be life altering, affecting not only your ability to urinate normally but also your sexuality. Women who lose their ovaries and fallopian tubes are no longer able to become pregnant and enter menopause immediately. In addition, removing part of the vagina during surgery can affect the ability to have sexual intercourse.

  In the past, the vast majority of men became impotent after a radical cystectomy. Now, new surgical procedures may prevent this problem in a very select group of men. Still, removing the prostate gland and seminal vesicles means that semen is no longer produced and sperm aren't released during ejaculation. Bladder cancer usually occurs in men after the years of active reproduction, but some men who have a cystectomy early in life choose to bank their sperm before surgery. Others may later decide on a procedure in which sperm are removed from their testicles.

Radiation therapy
This therapy uses high-energy X-rays to destroy cancer cells and shrink tumors. It's most often used after an operation to eliminate any remaining cancer cells. When surgical treatment isn't an option, radiation may sometimes be used instead, but it's much less effective than surgery.

In treating bladder cancer, radiation may either come from outside your body (external radiation) or from radioactive materials placed directly into your bladder (internal radiation).

External radiation is usually performed as an outpatient procedure, with treatments occurring five days a week for five to seven weeks.

You may find that you become tired during radiation therapy, especially during the last weeks of treatment. External radiation can also cause your skin to become red, tender and itchy — just as if you had sunburn. Women may also experience vaginal dryness, and men may have problems with impotence. Radiation may also cause bladder or bowel incontinence, impotence in men and irritation of the rectum, leading to diarrhea. These side effects are usually temporary. In the meantime, your doctor may be able to offer measures to make them more manageable.

Chemotherapy
This treatment uses drugs to destroy cancer cells. Your doctor may suggest having chemotherapy after an operation to eliminate any remaining traces of cancer, but sometimes you may have it before a surgical procedure in an effort to spare your bladder.

In most cases, two or more drugs are used in combination. They sometimes may be inserted directly into your bladder through your urethra — a procedure known as intravesical therapy. This treatment is commonly used after TUR to help prevent a very superficial cancer from recurring. You are likely to have intravesical therapy once a week for several weeks.

This isn't an option if cancer cells have penetrated deep into the bladder wall or spread to other organs. In that case, chemotherapy drugs are given intravenously so that they travel through your bloodstream to every part of your body (systemic chemotherapy). This treatment is given in several cycles, which gives your body a chance to recover between sessions.

Even so, the side effects of chemotherapy — hair loss, nausea, vomiting and fatigue — can be severe. They occur because chemotherapy affects healthy cells — especially fast-growing cells in your digestive tract, hair and bone marrow — as well as cancerous ones. Not everyone has these side effects, however, and there are now better ways to control them if you do.

Systemic chemotherapy may also reduce the number of white and red blood cells in your body, making you temporarily more prone to infections and bruising. In addition, some drugs used to treat bladder cancer may cause kidney damage. To help prevent kidney problems, you may be given intravenous fluids during your treatment and advised to drink lots of fluids.

Biological therapy
Biological therapy stimulates your body's own immune system to fight cancer. It's usually used after TUR to help prevent superficial bladder cancer from recurring. Bacille Calmette-Guerin (BCG), a bacterium used in vaccines against tuberculosis, is the most commonly used immune stimulant. It binds to your bladder, where it triggers a response that inhibits the formation and growth of tumors. BCG is administered directly into your bladder using a small, flexible tube (catheter) for two hours once a week. Treatment may last six or more weeks.

During treatment with BCG, you may have some bladder irritation or blood in your urine and feel as if you have the flu. Your doctor may suggest a medication to help reduce some of these signs and symptoms. If you have a persistent high fever — greater than 101.5 F — that doesn't respond to pain relievers, see your doctor promptly for treatment. This may indicate widespread infection of BCG, which can be serious.

Other treatments
Standard therapies for bladder cancer may not always be effective, or you may not be able to tolerate the side effects. In that case, several other treatments may be an option. One such option is photodynamic therapy (PDT).

This two-part treatment helps destroy bladder cancer cells. Initially you receive an injection of a chemical that is taken up by cancer cells but not by healthy ones. The cells containing the chemical are then exposed to light from a laser, which kills or severely damages them.

PDT may produce serious side effects, such as chronic bladder infections, bladder shrinkage and long-term sensitivity to sunlight. While promising, this therapy is only done at a limited number of centers and needs further study before it can be routinely recommended.

Bladder reconstruction
In radical cystectomy, your bladder is completely removed. Immediately afterward, your surgeon reconstructs your urinary system so that you can eliminate urine effectively. Several options for bladder reconstruction exist. The best approach for you depends on a number of factors, including your overall health and the extent to which the cancer has spread. In all cases, the goal is to maintain your quality of life as much as possible. Some reconstructive procedures include:

• Urinary conduit. This is the simplest operation with the least risk of complications. It involves isolating a segment of your small intestine and attaching one end of it to your ureters. The other end is connected to an opening (stoma) in your lower abdomen through which urine drains into a small bag. You wear the bag outside your body and empty it three or four times a day. In the evening you can use a larger bag that allows you to sleep through the night.
• Catheterizable stoma. This type of reconstruction eliminates the need for a bag. Instead, your surgeon fashions an interior pouch capable of holding 3 to 4 cups of urine. You drain the urine from the pouch several times a day using a catheter. Because the size of the pouch remains the same, you must also drain your urine during the night.
• Neobladder. During this complex reconstructive procedure, your surgeon literally recreates a bladder. This is accomplished by connecting the same type of internal pouch used in a catheterizable stoma to the tube that carries urine from your body (urethra). As a result, you're able to eliminate urine without having an external opening, although you may need to use a catheter inserted through your urethra. Neobladder reconstruction isn't an option if some or all of your urethra has been removed, and it may lead to a number of complications, including scarring, internal urine leakage and incontinence.

Although bladder cancer can't always be prevented, you can take these steps to help reduce your risk:

• Don't smoke. Not smoking means that cancer-causing chemicals in smoke can't collect in your bladder.
• Be careful with chemicals and private water sources. If you work with chemicals, follow all safety instructions to avoid exposure. If you have your own well, you may wish to have it tested to check for high levels of arsenic in the water.
• Drink plenty of fluids. Drinking liquids, especially water, dilutes toxic substances that may be concentrated in your urine and flushes them out of your bladder more quickly.
• Learn to love broccoli. A 10-year study conducted by researchers at the Harvard School of Public Health indicates that a high intake of cruciferous vegetables, such as broccoli and cabbage, may cut the risk of bladder cancer in men. Although eating plenty of fresh vegetables and fruits is important for overall health, only broccoli and cabbage seem to affect bladder cancer risk. The Harvard doctors studied only men, and it's not known if the results apply to women.
• Seek medical attention early. If you notice blood in your urine, see your doctor.

Living with cancer is never easy. But dealing with the physical effects of bladder cancer and its treatment can be especially difficult. This is particularly true if you have a stoma or urostomy bag. You may wonder how the changes in your body will affect your normal activities, your relationships and your sexuality.

It may help to know that having a stoma or urostomy bag doesn't mean you can't be active or live a normal life. The bags are small, inconspicuous under clothing and shouldn't leak. You can work, travel, exercise and even swim.

Even so, it may be difficult to come to terms psychologically with the physical changes you've experienced. Although there are no easy answers for coping with bladder cancer, the following suggestions may help:

• Find ways to make your life easier. If you have problems with incontinence or need to change a urostomy bag, try to sit in the back of a movie theater, concert hall or meeting room. That way you're less conspicuous if you need to leave for the toilet. Sit in an aisle seat on an airplane or train. Allow for breaks when planning long trips, seminars or excursions.

• Share your concerns with others. When you feel ready, consider talking to someone you trust about your concerns. This might be a friend, a family member, your doctor, a social worker, a spiritual adviser or a counselor. You may also find it helpful to talk to other people with bladder cancer. They can tell you how they've coped with problems similar to the ones you're facing.

  One of the best ways to do that is to join a support group for people with bladder cancer. Although support groups aren't for everyone, they can sometimes be a good resource for practical information about your disease. You may also find strength and encouragement in being with people who are facing the same challenges you are.

  If you're interested in learning more about support groups, talk to a doctor, nurse, social worker or psychologist. They may be able to put you in touch with a group in your area. Or check your local phone book, library or cancer organization. The National Cancer Institute also can provide a list of support groups. So can the American Cancer Society at (800) ACS-2345, or (800) 227-2345, or Cancer Care at (800) 813-HOPE, or (800) 813-4673.

  After deciding to participate in a group, try it out a few times. If it doesn't seem useful or comfortable, you don't have to continue.

• Don't be afraid of intimacy. Your natural reaction to changes in your body may be to avoid intimacy. Although it may not be easy, it's vitally important to discuss these feelings with your partner. You may also find it helpful to talk to a therapist, either on your own or together. Remember that you can express your sexuality in many ways. Touching, holding, hugging and caressing may become far more important to you and your partner. In fact, the closeness you develop may produce greater intimacy than you've ever had.

  Intimacy issues may be even harder to address if you're not currently in a committed relationship. You may worry that no one will ever find you attractive or desirable. In that case, the advice and understanding of a medical social worker or other therapist who understands bladder cancer can be a tremendous help. Your doctor may be able to recommend a qualified counselor. Or call the National Cancer Institute's toll-free information line, called the Cancer Information Service. It provides access to trained counselors and accurate, up-to-date information on all aspects of living with cancer. You can reach the Cancer Information Service 24 hours a day at (800) 4-CANCER, or (800) 422-6237.