Bladder cancer

Bladder cancer - Illnesses & conditions | NHS inform Home Illnesses and conditions Symptoms and self-help Tests and treatments Healthy living Care, support and rights Scotlands Service Directory 0 Home Illnesses and conditions Cancer Cancer types in adults Bladder cancer Bladder cancer About bladder cancer Symptoms of bladder cancer Causes of bladder cancer Diagnosing bladder cancer Treating bladder cancer Complications of bladder cancer Preventing bladder cancer About bladder cancer Bladder cancer is where a growth of abnormal tissue, known as a tumour, develops in the bladder lining. In some cases, the tumour spreads into the surrounding muscles. The most common symptom of bladder cancer is blood in your urine, which is usually painless. If you notice blood in your urine, even if it comes and goes, you should speak to your GP, so the cause can be investigated. Read about the symptoms of bladder cancer Types of bladder cancer Once diagnosed, bladder cancer can be classified by how far it hasspread. If the cancerous cells are contained inside the lining of the bladder, doctors describe it as non-muscle-invasive bladder cancer.This is the most common type of bladder cancer, accounting for 7 out of 10 cases.Most people dont die as a resultofthis type of bladder cancer. When the cancerous cells spread beyond the lining, into the surrounding muscles of the bladder, its referred to as muscle-invasive bladder cancer.This is less common,but has a higher chanceof spreading to other parts of the body and can be fatal. If bladder cancer has spread to other parts of the body, its known as locally advanced or metastatic bladder cancer. Read more about diagnosing bladder cancer Why does bladder cancer happen? Most cases of bladder cancer appear to be caused by exposure to harmful substances, which lead to abnormal changes in the bladders cells over many years. Tobacco smoke is a common cause andits estimated that half of all cases of bladder cancer are caused by smoking. Contact with certain chemicals previouslyused in manufacturing is also known to cause bladder cancer. However, these substances have sincebeen banned. Read more about the causes of bladder cancer and preventing bladder cancer Treating bladder cancer In cases of non-muscle-invasive bladder cancer, its usually possible to remove the cancerous cells while leaving the rest of the bladder intact. This is done using a surgical technique called transurethral resection of a bladder tumour (TURBT).Thisis followed by a dose of chemotherapy medication directly into the bladder, to reduce the risk of the cancer returning. In cases with a higher risk of recurrence, a medication known as Bacillus Calmette-Gurin (BCG) may beinjected into the bladder to reduce the risk of the cancer returning. Treatment for high-risk non-muscle-invasive bladder cancer, or muscle-invasive bladder cancer may involve surgically removing the bladder in an operation known as a cystectomy. When the bladder is removed, youll need another way ofcollecting your urine. Possible options include making an opening in the abdomen so urine can be passed into an externalbag, or constructing a new bladder out of a section of bowel. This will be done at the same time as a cystectomy. If its possible to avoid removing the bladder, or if surgeryis not suitable, a course of radiotherapy and chemotherapy may be recommended. Chemotherapy may sometimes be used on its own before surgery or before being combined with radiotherapy. After treatment for all types of bladder cancer, youll have regular follow-up tests to check for signs of recurrence. Read more about treating bladder cancer Who is affected? Bladder canceris more common in older adults, with more than half of all newcases diagnosed in peopleaged 75 and over. Bladder cancer is also more common in men than in women, possibly because in the past, men were more likely to smoke and work in themanufacturing industry. Symptoms of bladder cancer Blood in your urine is the most common symptom of bladder cancer. The medical name for this is haematuriaand its usually painless. You may notice streaks of blood in your urine or the blood may turn your urine brown. The blood isnt always noticeable and it may come and go. Less common symptoms of bladder cancer include: a need to urinate on a more frequent basis sudden urges to urinate a burning sensation when passing urine If bladder cancer reaches an advanced stage and begins to spread, symptoms can include: pelvic pain bone pain unintentional weight loss swelling of the legs When to seek medical advice If you ever have blood in your urine even if it comes and goes you should speak to your GP, so the cause can be investigated. Having blood in your urine doesnt mean you definitely have bladder cancer. There are other, more common, causes including: a urinary tract infection ,such as cystitis a kidney infection kidney stones urethritis an enlarged prostate gland ,in men Causes of bladder cancer Bladder cancer is caused by changes to the cells of the bladder. Its often linked with exposure to certain chemicals, but the cause isnt always known. What is cancer? Cancer begins with a change (mutation)in the structure of the DNA in cells, whichcanaffect how they grow. This means that cells grow and reproduce uncontrollably, producing a lump of tissue called a tumour. Increased risk Severalfactorshave been identified that can significantly increase your risk of developing bladder cancer. Smoking Smoking is the single biggest risk factor for bladder cancer. This is because tobacco contains cancer-causing (carcinogenic) chemicals. If you smoke for many years, these chemicals pass into your bloodstream and are filtered by the kidneysinto your urine. The bladder is repeatedly exposed to these harmful chemicals, as it acts as a store for urine. This can cause changes to the cells of the bladder lining, which maylead to bladder cancer. Its estimated thatjust over a thirdof all cases of bladder cancer are caused bysmoking. People who smoke may be up tofour times more likely to develop bladder cancer than non-smokers. Exposure to chemicals Exposure to certain industrial chemicals is the second biggest risk factor. Previous studies have estimated that this may account for around 25% of cases. Chemicals known to increase the risk of bladder cancer include: aniline dyes 2-Naphthylamine 4-Aminobiphenyl xenylamine benzidine o-toluidine Occupationslinked to an increased risk of bladder cancer are manufacturing jobs involving: dyes textiles rubbers paints plastics leather tanning Some non-manufacturing jobs have also been linked to an increased risk of bladder cancer. These include taxi or bus drivers, as a result of their regular exposure to the chemicals present in diesel fumes. The link between bladder cancer and these types of occupations was discovered in the 1950s and 1960s. Since then, regulations relating to exposure to cancer-causing chemicals have been made much more rigorous and many of the chemicals listed abovehave been banned. However,these chemicals are stilllinked with cases of bladder cancer now, as it can take up to30 years after initial exposure to the chemicals before the condition starts to develop. Other risk factors Otherfactors that can increase your risk of bladder cancer include: radiotherapy to treat previous cancers near the bladder, such as bowel cancer previous treatment withcertain chemotherapy medications, such ascyclophosphamide and cisplatin previous surgery to remove part of the prostate gland, during treatment for benign prostate enlargement having diabetes  bladder cancer is thought to be linked to certain treatments for type 2 diabetes having a tube in your bladder (an indwelling catheter) for a long time, because you have nerve damage that has resulted in paralysis long-term or repeated urinary tract infections (UTIs) long-term bladder stones having an early menopause (before the age of 42) an untreated infection called schistosomiasis , which iscaused by a parasite thatlives in fresh waterthis is very rare in the UK How does bladder cancer spread? Bladder cancer usually begins in the cells of the bladder lining. In some cases, itmay spread into surrounding bladder muscle. If the cancer penetrates this muscle, itcan spread to other parts of the body, usually through the lymphatic system. If bladder cancer spreads to other parts of the body, such as other organs, its known as metastatic bladder cancer. Diagnosing bladder cancer If you have symptoms of bladder cancer, such as blood in your urine, you should speak to your GP. Your GP may ask about yoursymptoms,family history and whether youve been exposed to any possible causes of bladder cancer,such assmoking. In some cases, your GP may request a urine sample, soit can be tested in a laboratory for traces of blood, bacteria or abnormal cells. Your GPmay also carry out a physical examination of your rectum and vagina,as bladder cancersometimes causes a noticeable lump that presses against them. If your doctor suspectsbladder cancer,youll bereferred to a hospital for further tests. In 2015, the National Institute for Health and Care Excellence (NICE) published guidelines to help GPs recognise the signs and symptoms of bladder cancer and refer people for the right tests faster.Find out who should be referred for further tests for suspected bladder cancer . At thehospital Some hospitals havespecialist clinics for people withblood in their urine (haematuria), while others have specialist urology departments for people with urinary tract problems. Cystoscopy If youre referred to a hospital specialist and they think you might have bladder cancer, you should first be offered a cystoscopy . This procedure allows the specialist to examine the inside of your bladder by passing a cystoscope through your urethra (the tube through which you urinate).A cystoscope isathin tube with a camera and light at the end. Before having a cystoscopy,a local anaesthetic gel is applied to your urethra (the tube through which you urinate) soyou dont feel any pain.The gel alsohelps the cystoscope to pass into the urethra more easily. The procedure usually takes about 5 minutes. Imaging scans You may be offered a CT scan or an MRI scan if the specialist feels they need a more detailed picture of your bladder. An intravenous (IV) urogram may also be used to look at your whole urinary system before or after treatment for bladder cancer. During this procedure, dye is injected into your bloodstream and X-rays are used to study it as it passes through your urinary system. Transurethral resection of a bladder tumour (TURBT) If abnormalities are found in your bladder during a cystoscopy, you should be offered an operation known as TURBT. This isso any abnormal areas of tissuecan be removed and tested for cancer (a biopsy). TURBTis carried out under general anaesthetic . Sometimes, a sample of the muscle wall of your bladder is also taken to check whether the cancer has spread, but this may be a separate operation within 6 weeks of the first biopsy . You should also be offered a dose of chemotherapy after the operation. This may help to prevent the bladder cancer returning if the removed cells are found to be cancerous. See treating bladder cancer for more information about the TURBT procedure Staging and grading Once these tests have been completed, it should be possible to tell you the grade of the cancer and what stage it is. Staging is a measurement of how far the cancer has spread. Lower-stage cancers are smaller and have a better chance of successful treatment. Grading is a measurement of how likely a cancer is to spread.The grade of a cancer is usually described using a number system ranging from G1 to G3. High-grade cancers are more likely to spread than low-grade cancers. The most widely used staging system for bladder cancer is known as the TNM system, where: T stands for howfar into the bladder the tumour has grown N stands for whether the cancer has spread into nearby lymph nodes M stands for whether the cancer has spread into another part of the body (metastasis), such as the lungs T stages The T staging system is as follows: TIS or CIS (carcinoma in situ)  a very early high-grade cancer confined to the innermost layer of the bladder lining Ta  the cancer is just in the innermost layer of the bladder lining T1  the cancerous cells have started to grow into the connective tissue beyond the bladder lining Bladder cancer up to the T1 stage is usually called early bladder cancer or non-muscle-invasive bladder cancer. If the tumour grows larger than this, its usually called muscle-invasive bladder cancer and is categorised as: T2  the cancer has grown through the connective tissue, into the bladder muscle T3  the cancer has grown through the layer of muscles, into the surrounding layer of fat If the tumour grows larger than the T3 stage, its considered to be advanced bladder cancer and is categorised as: T4  the cancer has spread outside the bladder, into surrounding organs N stages The N staging system is as follows: N0  there are no cancerous cells in any of your lymph nodes N1  there are cancerous cells in just one of your lymph nodes in your pelvis N2  there are cancerous cells in two or more lymph nodes in your pelvis N3  there are cancerous cells in one or more of your lymph nodes (known as common iliac nodes) deep in your groin M stages There are only two options in the M system: M0  where the cancer hasnt spread to another part of the body M1  where the cancer has spread to another part of the body, such as the bones, lungs or liver The TNM system can be difficult to understand, so dont be afraid to ask your care team questions about your test results and what they mean for your treatment and outlook. Treating bladder cancer The treatment options for bladder cancer largely depend on how advanced the cancer is. Treatments usually differbetween early stage, non-muscle-invasive bladder cancer and more advanced muscle-invasive bladder cancer. Multidisciplinary teams (MDTs) All hospitals use MDTs to treat bladder cancer. These are teams of specialists that work together to make decisions about the best way to proceed with your treatment. Members of your MDT may include: a urologist a surgeon specialising in treating conditions affecting the urinary tract a clinical oncologist a specialist in chemotherapy and radiotherapy a pathologista specialist in diseased tissue a radiologist a specialist in detecting disease using imaging techniques You should be given the contact details for a clinical nurse specialist, who will be in contact with all members of your MDT.Theyll be able to answer questions and support you throughout your treatment. Deciding what treatment is best for you can be difficult. Your MDT will make recommendations, but remember that the final decision is yours. Before discussing your treatment options, you may find it useful to write a list of questions to ask your MDT. Non-muscle-invasive bladder cancer If youve been diagnosed with non-muscle-invasive bladder cancer (stages CIS, Ta and T1), your recommended treatment plan depends on the risk of the cancer returning or spreading beyond the lining of your bladder. This risk is calculated using a series of factors, including: the number of tumours present in your bladder whether the tumours are larger than 3cm (1 inch) in diameter whether youve had bladder cancer before the grade of the cancer cells These treatments are discussed in more detail below. Low-risk Low-risk non-muscle-invasive bladder cancer is treated with transurethral resection of a bladder tumour (TURBT). This procedure may be performed during your first cystoscopy when tissue samples are taken for testing (see diagnosing bladder cancer ). TURBT is carried out under general anaesthetic . The surgeon uses an instrument called a cystoscope to locate the visible tumours and cut them away from the lining of the bladder. The wounds are sealed (cauterised) using a mild electric current, and you may be given a catheter to drain any blood or debris from your bladder over the next few days. After surgery,you may be given asingle dose of chemotherapy , directly into your bladder,using a catheter. The solution is kept in your bladder for around an hour before being drained away. Most people are able to leave hospital less than 48 hours after having TURBT and are able to resume normal physical activity within 2 weeks. You should be offered follow-up appointments at 3 months and nine months to check your bladder, using a cystoscopy . If your cancer returns after 6 months and is small,you may be offered a treatment called fulguration. This involves using an electric current to destroy the cancer cells. Intermediate-risk People with intermediate-risk non-muscle-invasive bladder cancer should be offered a course of at least 6 doses of chemotherapy. The liquid is placed directly into your bladder,using a catheter, and kept there for around an hour before being drained away. You should be offered follow-up appointments at 3 months, 9 months, 18 months, then once every year.Atthese appointments, your bladder will be checked using a cystoscopy.If your cancer returns within 5 years, youll be referred back to a specialist urology team. Some residue of the chemotherapy medication may be left in your urine after treatment, which could severely irritate your skin. It helpsif you urinate while sitting down and that youre careful not to splash yourself or the toilet seat. After passing urine, wash the skin around your genitals with soap and water. If youre sexually active, its important to use a barrier method of contraception , such as a condom. This isbecause the medication may be present in your semen or vaginal fluids, which can cause irritation. You also shouldnt try to get pregnant or father a child while having chemotherapy for bladder cancer, as the medication can increase the risk of having a child with birth defects. High-risk People with high-risk non-muscle-invasive bladder cancer should be offered a second TURBT operation, within 6 weeks of the initial investigation(see diagnosing bladder cancer ). A CT scan or an MRI scan may also be required. Your urologist and clinical nurse specialistwill discussyour treatment options with you, which will either be: a course of Bacillus Calmette-Gurin (BCG) treatment  using a variant of the BCG vaccine an operation to remove your bladder (cystectomy) The BCG vaccine is passed into your bladder through a catheter and left for 2 hours before being drained away. Most people require weekly treatments over a 6-week period. Common side effects ofBCG include: a frequent need to urinate pain when urinating blood in your urine (haematuria) flu-like symptoms, such as tiredness, fever and aching urinary tract infections IfBCGtreatment doesnt work, or the side effects are too strong, youll be referred back to a specialist urology team. You should be offered follow-up appointments every 3 months for the first 2 years, then every 6 months for the next 2 years, then once a year.Atthese appointments, your bladder will be checked using a cystoscopy. If you decide to have a cystectomy, your surgeon willneed tocreate an alternative way for urine to leave your body (urinary diversion). Your clinical nurse specialist can discuss your options for the procedure and how the urinary diversion will be created. Read about the complications of bladder cancer surgery for more information about urinary diversion and sexual problems after surgery. After having a cystectomy,you should be offered follow-up appointments including a CT scan at six and 12 months, andblood tests once a year. Men require an appointment to check their urethra once a year for 5 years. Muscle-invasive bladder cancer The recommended treatment plan for muscle-invasive bladder cancer depends on how far the cancer has spread. With T2 andT3 bladder cancer, treatment aims to cure the condition if possible, or at least control it for a long time. Your urologist, oncologist and clinical nurse specialistwill discussyour treatment options with you, which will either be: an operation to remove your bladder (cystectomy)  see above radiotherapy with a radiosensitiser Your oncologistshould also discuss the possibility of having chemotherapy before eitherof these treatments (neoadjuvant therapy), if its suitable for you. Radiotherapy with a radiosensitiser Radiotherapy is given by a machine that beams the radiation at the bladder (external radiotherapy). Sessions are usually given on a daily basis for 5 days a week over the course of 4 to 7 weeks. Each session lasts for about 10 to 15 minutes. A radiosensitisershould also be given alongside radiotherapy for muscle-invasive bladder cancer. This is a medicine which affects the cells of a tumour, to enhance the effect of radiotherapy. It has a much smaller effect on normal tissue. As well as destroying cancerous cells, radiotherapy can also damage healthy cells, which means it can cause a number of side effects. These include: diarrhoea inflammation of the bladder (cystitis) tightening of the vagina (in women), which can make having sex painful erectile dysfunction (in men) loss of pubic hair infertility tiredness difficulty passing urine Most of these side effects should pass a few weeks after your treatment finishes, although theres a chance theyll be permanent. Having radiation directed at your pelvis usually means youll be infertile for the rest of your life.However, most people treated for bladder cancer are too old to have children, so this isnt usually a problem. After having radiotherapy for bladder cancer,you should be offered follow-up appointmentsevery 3 months for the first 2 years, then every 6 months for the next 2 years, and every year after that.Atthese appointments, your bladder will be checked using a cystoscopy. You may also be offered CT scans of your abdomen, pelvis and chest after 6 months, 1 year and 2 years. A CT scan of your urinary tract may be offered every year for 5 years. Surgery or radiotherapy? Your MDT may recommend a specific treatmentbecause ofyour individual circumstances. For example, someone with a small bladder ormany existing urinary symptoms is better suited to surgery. Someone who has a single bladder tumour with normal bladder function is better suited for treatments that preserve the bladder. However, your input is also important, so you should discuss which treatment is best for you with your MDT. There are pros and cons of both surgery and radiotherapy. The pros of having a radical cystectomy include: treatment is carried out in one go you wont need regular cystoscopies after treatment, although other less invasive testsmay be needed The cons of having a radical cystectomy include: it can take up to 3 months to fully recover a risk of general surgical complications, such as pain, infection and bleeding a risk of complications from the use ofgeneral anaesthetic an alternative way of passing urine out of your body needs to be created, which may involve an external bag a high risk of erectile dysfunction in men (estimated at around 90%)as a result of nerve damage after surgery, some women may find sex uncomfortable, as their vagina may be smaller a small chance of a fatal complication, such as a heart attack , stroke or deep vein thrombosis (DVT) The pros of having radiotherapy include: theres no need to have surgery, which is often an important consideration for people in poor health your bladder function may not be affected, as your bladder isnt removed theres less chance of causing erectile dysfunction (around 30%) The cons of having radiotherapy include: youll require regular sessions of radiotherapy for 4 to 7 weeks short-term side effects are common,such as diarrhoea, tiredness and inflammation of the bladder (cystitis) a small chanceof permanently damaging the bladder, which could lead to problems urinating women may experience a narrowed vagina, making sex difficult and uncomfortable Chemotherapy In some cases,chemotherapy may be used during treatment for muscle-invasive bladder cancer. Instead of medication being put directly into your bladder, its put into a vein in your arm. This is called intravenous chemotherapy and can be used: before radiotherapy and surgery to shrink the size of any tumours in combination with radiotherapy before surgery (chemoradiation) to slow the spread of incurable advanced bladder cancer (palliative chemotherapy) There isnt enough evidence to say whether chemotherapy is an effective treatment when its given after surgery to prevent the cancer returning. Its usually only used this way as part of a clinical trial .See clinical trials for bladder cancer for more information. Chemotherapy is usually given over a few consecutive days at first. Youll then have a few weeks off to allow your body to recover before the treatment begins again. This cycle will be repeated for a few months. As the chemotherapy medication is being injected into your blood, youll experience a wider range of side effects than if you were having chemotherapy directly into the bladder. These side effects should stop after the treatment has finished. Chemotherapy weakens your immune system, making you more vulnerable to infection. Its important to report any symptoms of a potential infection, such as a high temperature, persistent cough or reddening of the skin, to your MDT. Avoid close contact with people who are known to have an infection. Otherside effects of chemotherapy can include: nausea vomiting hair loss lack of appetite tiredness Locally advanced or metastatic bladder cancer The recommended treatment plan forlocally advanced or metastatic bladder cancerdepends on how far the cancer has spread. Your oncologist should discuss your treatment options with you, which may include: a course of chemotherapy treatments to relieve cancer symptoms Chemotherapy If you receive a course of chemotherapy, youll be given a combination of drugs to help relieve the side effects of treatment. Treatment may be stopped if chemotherapy isnt helping, or a second course may be offered. Relieving cancer symptoms You may be offered treatment to relieve any cancer symptoms. This may include: radiotherapy to treat painful urination, blood in urine, frequently needing to urinate or pain in your pelvic area treatment to drain your kidneys, if they become blocked and cause lower back pain Palliative care If your cancer is at an advanced stage and cant be cured, your MDT should discuss how the cancer will progress and which treatments are available to ease the symptoms. You can be referred to a palliative care team, who can provide support and practical help, including pain relief. Read more about end of life care Complications of bladder cancer A diagnosis of bladder cancer, and some treatments for the condition, can have a significant impact on your life. Emotional impact The emotional impact of living with bladder cancer can be huge. Many people report experiencing a kind of rollercoaster effect. For example, you may feel down at receiving a diagnosis,up whenthe canceris removed, and down again as you try to come to terms with the after-effects of your treatment. This type of emotional disruption can sometimes trigger feelings of depression . Signs that you may be depressed include: having continuous feelingsof sadnessor hopelessness no longer taking pleasure in the things you enjoy Contact your GP for advice if you think you may be depressed. Theres a range of relatively successful treatments for depression, including antidepressant medication andtherapies such as cognitive behavioural therapy (CBT). Read more about coping with cancer Urinary diversion Ifyour bladder is removed, an alternative way of passing urine out of yourbody will be created during the operation. This is called urinary diversion. There are various types of urinary diversion, which are described below. In some cases, you may be able to make a choice based on your personal preferences. However, certain treatment options will not be suitable for everyone. Your multidisciplinary team (MDT) can provide information on the most suitable options for you. Urostomy A urostomy iscarried out during a radical cystectomy. A small section ofthe small bowel isremoved andconnected to your ureters (the 2 tubes that normally carry urine out of the kidneys). The surgeonthen creates a small hole in the surface of your abdomen and the open end of the removed bowel is placed in this hole, creating an opening known as a stoma. Aspecial waterproofbagis placed over the stoma to collect urine. Astoma nurse will teach you how to care for your stoma, and how and when to change the bag. Continent urinary diversion Continent urinary diversion is similar to a urostomy, butwithout an external bag. Instead, a section of your bowelis used to create a pouch inside your body that stores urine. The ureters are connected to the pouch and the pouch is connected to an opening in the abdominal wall.A valve in the opening (stoma) prevents urine leaking out. The pouch is emptied using athin, flexible tube(catheter). Most people need to empty their pouch about 4 or 5 times a day. Bladder reconstruction In some cases it may be possible to create a new bladder, known as a neobladder. This involves removing a section of your bowel and reconstructing it into a balloon-like sac, before connecting it to your urethra (the tube that carries urine out of the body) at one end and your ureters at the other end. However, bladder reconstruction isnt suitable for everyone. Youll be taught how to empty your neobladder by relaxing the muscles in your pelvis, whiletightening the muscles in your abdomen at the same time. Your neobladder wont contain the same types of nerve endings as a real bladder, so you wont get the distinctive sensation that tells you to pass urine. Some people experience a feeling of fullness inside their abdomen, while others have reported they feel like they need to pass wind. Because ofthe loss of normal nerve function, most people with a neobladder experience some episodes of urinary incontinence , which usually occurs during the night, while theyre asleep. You may find it useful to empty your neobladder at set times during the day, including before you go to bed, to help prevent incontinence. Sexual problems Erectile dysfunction Contact yourMDT if you lose the ability to obtain or maintain an erection after a radical cystectomy. It may be possible for you to be treated with a type of medicine known as phosphodiesterase type 5 inhibitors (PDE5). PDE5s work by increasing the blood supply to your penis. PDE5s are sometimes combined witha device called a vacuum pump, which consists of acylinder connected to a pump. The penis is placed inside the cylinder and the air is pumped out. This creates a vacuum that causes blood toflow into the penis. A rubber ring is then placed around the base of the penis, which allows an erection to be maintained for around 30 minutes. Read more about treating erectile dysfunction Narrowing of the vagina Both radiotherapy and cystectomy can cause a womans vagina to become shortened and narrowed, which can make penetrative sex painful or difficult. There are 2 main treatment options available if you have a narrowed vagina. The first is to apply hormonal cream to the area, which should help to increase moisture inside your vagina. The second is to use vaginal dilators. These areplastic cone-shaped devices of various sizesthat are designed to gently stretchyour vagina and make it more supple. Its usually recommended that youusedilatorsfor a 5 to10-minute period every day, starting with the dilator that fits in easiest first andgradually increasing the size, as your vagina stretches over the following weeks. Many women find this an embarrassing issue to discuss, but the use of dilators is a well-recognised treatment for narrowing of the vagina. Your specialist cancer nurse should be able to provide more information and advice. You may find that themore often you have penetrative sex, the less painful it becomes. However, it may be several months before you feel emotionally ready to be intimate with a sexual partner. The Macmillan Cancer Support website has information and a video about cancer and sexuality Preventing bladder cancer Its not always possible to prevent bladder cancer, but some risk factors have been identified, which may increase your risk of developing the condition. Stopping smoking If you smoke, giving up is the best way to reduce your risk of developing bladder cancer and preventing it from recurring. If you decide to stop smoking, youcould contact the Quit Your Way .