Treatment into the bladder

Intravesical therapy for bladder cancer means putting liquid drugs directly into the bladder through a tube called a catheter. The aim of this treatment is to treat the cancer and stop it from coming back or spreading into the deeper layers of the bladder.

After surgery to remove early bladder cancer you have a catheter (tube) put into your bladder. Your doctor or specialist nurse puts a chemotherapy drug into the tube. The chemotherapy drug may be mitomycin C, epirubicin or doxorubicin. The catheter may then be taken out. You have to try not to pass any urine for the next 2 hours. This gives the treatment time to be in contact with the lining of the bladder. You then pass urine naturally to get rid of the chemotherapy drug. Or your nurse drains the chemotherapy out through a catheter. For some people with early bladder cancer, this is all the treatment they need.

People who have CIS, Ta and T1, or grade 2 or 3 tumours need to have further treatment into the bladder with

• Chemotherapy drugs
• BCG vaccine

People who have grade 2 tumours usually have further treatment with chemotherapy into the bladder (intravesical chemotherapy). This is to further reduce the chance of the cancer coming back or spreading. You have a solution of a chemotherapy drug (mitomycin, epirubicin or doxorubicin) put into your bladder weekly for 6 weeks. You may also have this treatment if your cancer comes back after the initial surgery and chemotherapy treatment.

The chemotherapy is a liquid given into the bladder through a flexible tube (catheter). For 6 hours after the treatment, you have to be careful when you pass urine. The urine contains some chemicals from the chemotherapy. 

Men should sit down to pass urine, to reduce the chance of splashing. You should try not to get any urine on your hands because the chemotherapy may irritate your hands.

Giving chemotherapy into the bladder does not have as many side effects as having chemotherapy tablets or injections. The drug tends to stay in your bladder and very little of it gets into the bloodstream.

The main side effect is irritation of the bladder. You may feel as if you have a bad urine infection (cystitis). If you have this side effect you will feel that you want to pass urine very often and it may be uncomfortable when you do pass urine. About 1 out of 10 people (10%) develop a rash on their hands or feet for a short time after having the treatment.

People who have CIS or grade 3 tumours usually have treatment with BCG into the bladder (intravesical BCG). In some cases, your doctor may suggest you have BCG for grade 2 early bladder cancer.

BCG is a vaccine for tuberculosis (TB). It is also very good at helping to stop bladder cancers growing back in the bladder or spreading into the deeper layers of the bladder. You usually have BCG treatment weekly for 6 weeks. You may also have another BCG intravesical therapy 6 weeks after your last weekly treatment, and then every few weeks or months for the next 3 years. This is called maintenance BCG therapy.

The BCG is a liquid and your doctor or nurse put it into your bladder through a tube (catheter). They usually then remove the catheter. You should not pass urine for 2 hours. When you do pass urine, you have to be careful for 6 hours after the treatment because the vaccine contains live TB. Men should sit down to pass urine, to reduce the chance of splashing. You should try not to get any urine on your hands. After you've been to the loo, pour about half a pint of neat bleach into the toilet bowl and leave it for 15 minutes before flushing. This makes sure you are not flushing live TB into the sewer system. Then, as always, wash your hands as the treatment may irritate your skin.

Doctors are not quite sure how BCG works for bladder cancer. It seems to encourage cells of the immune system to grow and become very active in the lining of the bladder. BCG seems to work as a type of immunotherapy. These cells of the immune system probably kill off any cancer cells that might grow back or have been left behind in the bladder lining. 

A review of medical studies in this area has found that this treatment does help to stop bladder cancers coming back in many people.

You probably won't have too many side effects from this treatment, although it can cause more side effects than chemotherapy into the bladder.

• About 2 out of 3 people have an irritated bladder which feels a bit like having a urine infection
• About 7 out of 10 people want to pass urine more often than usual
• About 1 in 4 people have blood in their urine
• About 1 in 2 people have flu like symptoms for 24 to 48 hours after each treatment
• About 1 or 2 out of 100 people have painful joints

If you have any of these symptoms, tell your doctor at your next appointment.

There is also a very small chance that some of the TB could get into your system and give you TB symptoms such as

• Fever and chills
• Joint pain
• Feeling sick or vomiting
• Cough
• Skin rash
• Feeling extremely tired

These effects only happens to fewer than 1 person in every 100 who has this treatment. It is important that you tell your doctor straight away if you have any of these symptoms or have a high temperature for more than 48 hours. You may need treatment with anti TB drugs and should not wait until your next appointment to let your doctor know.

There is currently a worldwide shortage of BCG vaccine. This means that your specialist may suggest another treatment for you. Which treatment you have will depend on your particular situation.

If you have early bladder cancer that has been removed, but your specialist is concerned about the risk of it coming back, they may suggest removing your bladder. This is the suggested treatment for some patients in this situation already. Whether you can have this done depends on whether you are fit enough to have the surgery. Although a more major treatment to undergo, this treatment has a very high cure rate - even higher than BCG. Your specialist will obviously discuss this with you fully before you come to a decision. There is information about having your bladder removed in our section on treating invasive bladder cancer.

If for any reason this type of surgery isn't suitable for you, you may have chemotherapy into the bladder instead of BCG. The link will take you to information about this above, on this page.

If you have already finished your first course of BCG treatment and have been having regular maintenance treatment, this will have to stop if BCG is not available. Instead, your specialist will regularly check inside your bladder to make sure that any sign of your cancer coming back is picked up as soon as possible. You are most likely to have a check cystoscopy every 6 months. The British Association of Urologists say that recent research shows the risk from stopping maintenance BCG treatment is very small, as long as you have these regular checks.  If supplies become available, there is no reason why you can't start maintenance BCG once again.

Research studies are always going on into different treatments. Doctors around the world are looking into using different substances for intravesical therapy to see if they can find treatments that work better than chemotherapy and BCG. They are looking at

• IL2 (Aldesleukin) and interferon
• Photodynamic therapy

IL2 (interleukin) and interferon

There is information about IL2 and its side effects and interferon and its side effects in our cancer drugs section. But you are not likely to have too many side effects if you are having treatment into the bladder.

Photodynamic therapy

This treatment uses an anti cancer drug that only works when light shines on it. It is called photodynamic therapy (PDT). Your doctor either puts the drug directly into your bladder (through a catheter) or less commonly you may have it into your bloodstream.

After a few hours, you have a catheter put into your bladder again. The doctor fills your bladder with salt water (saline). Then they shine a laser light at the bladder lining. The light activates the drug to kill any cancer cells that are there. The treatment works in 3 ways. PDT

• directly kills the bladder cancer cells
• damages the blood vessels that bring food and oxygen to the tumour
• triggers your immune system to destroy the tumour

This treatment is experimental at the moment. Your specialist is only likely to suggest it if treatment with intravesical BCG or chemotherapy has not worked for you.