Bladder Cancer Diagnosis: Tests and Markers to Know

Written by Alyson Powell Key
Medically Reviewed by Laura J. Martin, MD on March 10, 2026

Doctors diagnose bladder cancer using different tests, including a physical exam, imaging tests, lab tests, and a biopsy. If it turns out that you do have cancer, you'll have more tests to find out the stage of the cancer.

To find out whether you have bladder cancer, the first thing your doctor will probably do is a complete medical history. They'll ask you about your overall health, as well as anything that increases your risk, like having a family member who had bladder cancer. Next, they'll probably do a physical exam. A physical exam helps your doctor spot signs of bladder cancer.  They can do this by either a pelvic exam or a digital rectal exam (DRE).

Pelvic exam

Women may have a pelvic exam, where a doctor will check for tumors. They can also figure out the size of the tumor and how far it has spread.

Digital rectal exam

This test, also known as a DRE, involves your doctor inserting a gloved, lubricated finger into your bottom (rectum). It's a brief procedure, and you may feel slight discomfort. Tell your doctor if you have hemorrhoids or an anal fissure, since a DRE can aggravate these conditions.

This exam may also  allow your doctor to feel a tumor in your bladder. It may also give them an idea of how big it is or whether it has spread.

When you pee in a cup at your doctor's office, there are a number of things they and other health professionals can look for:

  • Urinalysis. Your doctor will check to see if there's any blood, or other substances, in your urine.
  • Urine cytology. Your doctor will use a microscope to check your urine for cancer cells.
  • Urine culture. Your doctor will send your urine to a lab. After a few days, lab technicians will check to see what kinds of germs grow in it. These results will tell your doctor if you have a bladder infection.
  • Urine tumor marker tests. These look for substances that are released by bladder cancer cells. Your doctor may use one or more of these along with a urine cytology to see if you have the disease.

When you have bladder cancer, your cells make certain substances (called tumor markers or biomarkers) that a urine or blood test can help to identify. Here's a closer look at some of the tests:

NMP22

NMP22 is a protein that your body makes in higher amounts if you have bladder cancer. A urine test checks for it.

Bladder tumor antigen (BTA) 

A urine test can help detect a substance called bladder tumor antigen (BTA), also known as CFHrp.

Cytokeratin

Cytokeratins, especially a protein called CK20, play a role in diagnosing and classifying bladder cancer.

Hyaluronic acid and cancer

Scientists have linked higher-than-normal levels of hyaluronic acid (a substance that your body naturally makes) in your urine to bladder cancer. This is different from the hyaluronic acid that is used in skin care products, which has no connection to cancer.

Carcinoembryonic antigen (CEA)

A carcinoembryonic antigen (CEA) test checks the level of a protein in your blood called CEA. This protein has sugars attached to it, and both normal and cancerous cells make it.

Prostate-specific antigen (PSA)

This test is used for prostate cancer. But because bladder cancer and prostate cancer share the same area and may have similar symptoms, your doctor may want to do this test.

Alpha-fetoprotein (AFP)

Alpha-fetoprotein (AFP) is a substance found at higher levels in the blood of people with certain kinds of bladder cancer. It can also help doctors to track how well you respond to treatment or if your condition is advancing.

CA 19-9

The level of CA 19-9 protein in your blood can show how aggressive bladder cancer is. It's usually high in people whose cancer has spread to other parts of the body. While the test can help doctors predict how serious your cancer is, it's not as accurate for diagnosis.

This urine test detects changes to your chromosomes that often appear in bladder cancer cells. Doctors use the test to watch for bladder cancer to come back in people who've had the condition, and check for bladder cancer in those who have blood in their urine. One review found that UroVysion detects around 72% of urothelial cancers, a common type of bladder cancer.

Methylation is a chemical process in which your body adds a small molecule, known as a methyl group, to DNA. Adding methyl groups can alter how these molecules work. Changes in the methylation patterns of genes can raise your chances of forming cancer and other diseases. Doctors use changes in methylation biomarkers found in your urine to help detect bladder cancer. Studies show testing for methylation can detect 92% of bladder cancers.

Your doctor will place a cystoscope through the opening of your urethra – the duct that you pee through – and into your bladder.

The cystoscope is a thin tube with a light and a video camera on the end. Your doctor will inject salt water through the tube and into your bladder. This will allow them to see the inner lining of your bladder with the camera. Blue light and white light types of cystoscopy used with imaging agents are particularly effective in helping to detect invasive bladder cancer.

They may give you a medicine to numb your urethra and bladder. If the procedure is done in an operating room, you'll be given anesthesia, so you won't be awake.

There are some advances in cystoscopy technology. Some bladder cancer centers use blue light cystoscopy, which is an enhanced imaging technique to help doctors spot tumors more easily than the standard procedure.

Before surgery, doctors place a catheter tube into your bladder through your urethra, which releases medicine into the bladder.

"That medicine is absorbed by bladder cancer," explains Joseph Feliciano, MD, a urologist at Lehigh Valley Health Network in Pennsylvania. "We turn on a special light filter, and the cancer beams in the dark. You can detect more tumors and resect more efficiently and leave a healthy bladder behind."

If your doctor finds something that doesn't look right during your cystoscopy, they'll take a sample of it (biopsy) to see whether it's cancer.

During a TURBT, your surgeon will remove the tumor and some of the bladder muscle near it. They'll be sent to a lab to check for cancer.

These use X-rays, magnetic fields, sound waves, or radioactive substances to create pictures of what's happening inside your body. Here are just a few of the imaging tests your doctor may use to see if you have bladder cancer:

  • Intravenous pyelogram (IVP). This is an X-ray of your urinary system. Your doctor will inject dye into a vein. It'll highlight tumors in your urinary tract.
  • Retrograde pyelogram. Your doctor will insert a thin tube (catheter) into your urethra and bladder. They'll inject dye through the catheter so they can see the lining of the bladder. If there are any tumors in your urinary tract, they'll show up here.
  • CT scan. This will give your doctor an image of your kidney, bladder, and ureters (tubes that carry pee from your kidneys to your bladder). It'll show tumors in your urinary tract. It can also show lymph nodes that contain cancer.
  • MRI. This test uses radio waves and powerful magnets to create images of your urinary tract.
  • Ultrasound. Sound waves create pictures of your urinary tract. This test allows your doctor to see how big a bladder tumor is.
  • Chest X-ray. If cancer in your bladder has spread to your lungs, this test will allow your doctor to see it.
  • Bone scan. Cancer that has spread from your bladder to your bones will be visible through this scan.

If your doctor suspects you have bladder cancer, they'll use different tests to confirm a diagnosis. 

Tests range from urine tests to check for blood, cancer cells, and substances released by cancer cells, to imaging tests such as X-rays, CT scans, or MRIs to see what's happening inside your body.

Your doctor will also ask about your family medical history, perform a physical exam, and may perform a cystoscopy and biopsy.

What is usually the first symptom of bladder cancer?

Blood in your urine is usually the first symptom. You may notice a change in the color of your pee, or it may only become apparent during a urine test (urinalysis). Most of the time, blood in your pee means you have an infection, a kidney stone, or another condition unrelated to cancer.

What are the red flags of bladder cancer?

Along with blood in your urine, other symptoms of bladder cancer include:

  • Needing to pee more often than normal, including at night
  • Pain or burning when you pee
  • The urge to pee even when your bladder is empty
  • Trouble peeing or a weak stream

Can you have bladder cancer for years and not know it?

Yes. A delayed diagnosis can especially happen to females. That's because they tend to ignore blood in the urine, connecting it instead to their period or menopause. Plus, doctors may misdiagnose this group with a urinary tract infection or another condition that isn't cancer.

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