BCG bladder treatment
A liquid medicine made from a weakened germ, placed into the bladder through a thin catheter, that trains the immune system to attack bladder cancer cells. It is the standard treatment after TURBT for high-risk early bladder cancer.
Also called BCG, BCG therapy, BCG immunotherapy, intravesical BCG, Bacillus Calmette-Guérin, Bacillus Calmette-Guerin, TICE BCG, bladder immunotherapy
- Where
- Urology clinic treatment room
- Anesthesia
- None; numbing gel for the catheter
- Time in the room
- About 15 minutes in the clinic, then you hold the medicine for about 2 hours
- Hospital stay
- Same day
- Going home with
- None after each treatment
- Back to normal
- Most people feel like themselves within 1 to 2 days after each treatment
- Back to work
- Often the next day; many people return the same day once they have emptied the medicine
Overview
BCG, short for Bacillus Calmette-Guérin, is a weakened form of a germ related to the one that causes tuberculosis. It was first made as a tuberculosis vaccine about a hundred years ago. When it is placed inside the bladder, it sets off a strong immune reaction in the bladder lining. That reaction kills cancer cells and lowers the chance that tumors come back or grow deeper.
BCG is given after a TURBT has removed all the tumor that can be seen. A nurse or doctor passes a thin catheter into your bladder, lets the BCG liquid flow in, and takes the catheter out. You hold the medicine for about 2 hours, then urinate it out, following a few simple safety steps.
Treatment has two parts. Induction is one treatment a week for 6 weeks. If the cancer responds, maintenance follows: 3 weekly treatments at set times, for 1 year for intermediate-risk cancer and up to 3 years for high-risk cancer, as the AUA/SUO guideline recommends.
Most people have bladder irritation, and some have tiredness or mild flu-like feelings, for a day or two after each treatment. These are signs the immune system is reacting. Serious infection from BCG is rare. BCG has been in short supply in the United States at times, and your team may adjust the plan to follow national guidance when that happens.
The parts of your body involved
The bladder is a hollow muscular bag lined by a thin layer of cells called the urothelium. Early bladder cancers live in this lining. Some form raised tumors that a TURBT can remove. Others, called carcinoma in situ (CIS), spread flat across the lining like a red velvet patch and are hard to remove with a scope. Because BCG bathes the whole lining, it reaches cancer cells everywhere in the bladder, including flat CIS and cells too small to see.
- Lining (urothelium)
The inner surface of the bladder, where early bladder cancer grows and where BCG does its work.
- Carcinoma in situ (CIS)
Flat, high-grade cancer cells lying on the lining. BCG is the main treatment for CIS.
- Healing TURBT area
The spot where a tumor was removed. BCG starts only after it has healed, usually 2 to 4 weeks after surgery.
- Bladder muscle
The thick muscle wall. BCG is meant for cancer that has not reached the muscle.
- Urethra
The tube from the bladder to the outside. The catheter passes through it to deliver the medicine.
Why it’s done
BCG is recommended when early bladder cancer has a high chance of coming back or growing deeper. It is the most effective medicine placed in the bladder for these cancers and is backed by decades of research.
- High-grade tumors
High-grade Ta tumors come back often and can grow deeper. BCG lowers both risks.
- T1 tumors
Tumors that have grown into the connective layer under the lining are treated with BCG after they are fully removed, often after a repeat TURBT confirms the stage.
- Carcinoma in situ (CIS)
Flat CIS can cover large areas and cannot be fully removed with a scope. BCG is the main treatment, and most people with CIS respond to it.
- Intermediate-risk tumors that keep coming back
For people whose low-grade tumors return again and again, BCG is one of the options to break the cycle.
- Keeping the bladder
For many people, BCG controls the cancer and allows the bladder to be kept, with bladder removal held in reserve if the cancer does not respond.
Other options
- Chemotherapy in the bladder
Gemcitabine, mitomycin, or gemcitabine followed by docetaxel can be placed in the bladder the same way. These are common for intermediate-risk tumors, and for high-risk cancer when BCG is not available or has not worked. Large trials have been comparing gemcitabine and docetaxel with BCG directly; ask your urologist about the latest results.
- Removing the bladder early
For some very high-risk early cancers, such as T1 tumors with features that predict spread, removing the bladder right away may offer the best chance of cure. It is also the standard option when BCG has not worked.
- Checkups alone
Watching high-risk tumors with cystoscopy alone, without BCG, leaves a higher chance of return and growth. It may be chosen by people who cannot have BCG or prefer not to.
- Newer treatments when BCG stops working
For cancer that keeps coming back despite BCG, newer options include immunotherapy given by vein, a gene therapy placed in the bladder, an immune-boosting drug given together with BCG, and a slow-release gemcitabine device placed in the bladder. Clinical trials are another choice.
Getting ready
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Before your first treatment
The day before
The morning of each treatment
The procedure, step by step
Press play or pick a step. Each drawing shows what your surgeon is doing at that moment. Your team may do some steps differently.
1. Checking in
The nurse asks how you felt after the last treatment and tests your urine for blood or signs of infection. If you have an infection, visible blood or a fever, the treatment is postponed. The pharmacy prepares the BCG with special safety steps, because it is a live germ.
After the procedure
Right afterward
- Leaving the clinic
Most people leave right after the catheter is removed and hold the medicine on the way home. If you live far away, you may hold it in the clinic or nearby and empty it there.
- Driving
No sedation is used, so most people can drive themselves. Plan the drive so you are home well before the 2 hours are up.
- After the first treatment
Some clinics keep you a little longer after your first dose to make sure you feel well.
- When you get home
Rest, keep the medicine in for the full 2 hours if you can, then empty it using the safety steps and start drinking fluids.
At home
- Toilet safety for 6 hours
Sit to urinate, use bleach in the toilet if your team asks you to, and wash your hands and genital skin after each time you urinate. Clean any splashes on the toilet seat.
- Drink to flush
Once you have emptied the BCG, drink extra fluids for the rest of the day, often about 8 to 10 cups, unless you have been told to limit fluids.
- Bladder irritation
Burning, urgency and frequent urination often start a few hours after treatment and last 1 to 3 days. Acetaminophen, phenazopyridine or a bladder-calming medicine can help. Tell your team if symptoms last more than 2 to 3 days.
- Flu-like feelings
Tiredness, chills, aches and a low fever can last up to 48 hours. Rest and acetaminophen help. Call if the fever is 101.3°F (38.5°C) or higher or lasts more than 48 hours.
- Blood in the urine
Pink urine for a day is common. Red urine or clots should be reported.
- Laundry
Wash clothes or sheets that get urine on them separately from other laundry.
- Sex
Many teams advise avoiding sex for 48 hours after each treatment and using condoms during the whole course. Avoid pregnancy during treatment. Practice varies, so ask your team.
- Activity and work
There are no lifting or driving limits. Most people go about their normal routine and work, planning for a quieter evening after each treatment.
- Other doctors and antibiotics
Tell any doctor who treats you that you are receiving BCG, especially before you start an antibiotic.
Recovery timeline
- 2 to 4 weeks after TURBTFirst treatment
Induction begins once the bladder has healed. The first treatments are often the easiest.
- Weeks 1 to 6Induction
One treatment a week. Bladder irritation usually builds over the course and is strongest in weeks 4 to 6.
- About 3 monthsFirst check
Cystoscopy and urine tests, and sometimes biopsies, show whether the cancer has responded.
- Months 3 and 6Early maintenance
If the bladder is clear, you get 3 weekly treatments at about 3 months and again at 6 months after starting.
- Every 6 monthsOngoing maintenance
Three weekly treatments every 6 months, up to 1 year for intermediate-risk cancer or 3 years for high-risk cancer, as tolerated.
- First 2 yearsClose checkups
Cystoscopy and urine tests about every 3 months. People with high-risk cancer also get imaging of the kidneys and ureters every 1 to 2 years.
- Long termSpaced-out checkups
If all stays clear, checkups spread to every 6 months and then once a year.
What it feels like
BCG is a series of short office visits spread over months, so the experience is about routine and stamina. Most people find the first few treatments easy and the later ones more tiring. Knowing what is normal helps you keep going.
The first catheter
Many people feel nervous or embarrassed about the catheter. The insertion feels like pressure and a quick sting.
What helpsBreathing out slowly and relaxing your pelvic muscles, as if starting to urinate, helps the catheter pass. It gets easier with each visit.
Holding for 2 hours
The urge to urinate can build toward the end, and some people watch the clock.
What helpsLimiting fluids beforehand makes holding easier. Distraction helps. If you cannot hold it, emptying a little early is better than straining to the point of pain; tell your team.
The evening after
Burning and needing to urinate often, including at night, are common, especially in the later weeks.
What helpsFluids after emptying, acetaminophen, phenazopyridine and a bladder-calming medicine can take the edge off. Plan a quiet evening.
The day after
Some people feel tired, achy or chilled, like the start of a cold. It usually passes within 48 hours.
What helpsRest and acetaminophen. A fever of 101.3°F (38.5°C) or higher, or any fever lasting more than 48 hours, needs a call to your team.
The bathroom routine
Some people feel uneasy, as if they are a danger to their family, when they use bleach or wash after urinating.
What helpsThese are simple precautions and the risk to others is very low when you follow them. Most families settle into the routine quickly.
Weeks 4 to 6
Symptoms can be at their strongest, and some people are tempted to stop.
What helpsTalk to your team before skipping a dose. They can adjust medicines, delay a week, or sometimes lower the dose so you can complete the course.
A clear cystoscopy
Relief, sometimes mixed with dread about maintenance.
What helpsMaintenance treatments come in short sets of 3 and are easier to plan around once you know your pattern.
How well it works
BCG has worked when follow-up cystoscopies and urine tests show no cancer. The first check is about 3 months after the first dose, and checks continue on a regular schedule for years.
- For CIS
Success means the red patches are gone, urine cytology (looking for cancer cells in urine) is normal, and any biopsies are clear. Most people with CIS respond to BCG.
- Fewer returns
BCG lowers the chance that tumors come back compared with TURBT alone, and maintenance keeps that benefit going longer.
- Less chance of growing deeper
BCG with maintenance lowers the chance that high-risk cancer grows into the muscle, which is the main reason it is used.
- If cancer persists or returns
Your team may give a second course of BCG. If high-grade cancer keeps coming back despite adequate BCG, it is called BCG-unresponsive, and options include bladder removal, newer bladder medicines, immunotherapy, or a clinical trial.
- Ongoing checkups
Cystoscopy and urine tests about every 3 months for 2 years, then less often. People with high-risk cancer also need periodic imaging of the kidneys and ureters.
Risks
Every operation has risks. These are the ones people ask about most, with honest odds where good numbers exist. Your surgeon’s own results matter more than averages.
Common
Burning, urgency and frequent urination for 1 to 3 days after a treatment. It affects most people at some point and tends to build over the course.
Fatigue, mild chills, aches or a low fever for up to 48 hours. Usually managed with rest and acetaminophen.
Light pink urine for a day after treatment is common, from the catheter or the inflamed lining.
Some people leak a little while holding the medicine. Wearing a pad and the safety steps handle this.
Less common
Can look like BCG irritation. A urine test tells them apart. Treated with antibiotics chosen with BCG in mind.
Strong side effects sometimes mean postponing a week or lowering the dose. Some people stop BCG because of side effects.
A fever of 101.3°F (38.5°C) or higher, or lasting more than 48 hours, needs evaluation to make sure BCG has not spread beyond the bladder.
Some people develop an immune reaction that causes painful joints or eye irritation. It usually settles after stopping BCG and with treatment.
In men, BCG can inflame the prostate, which can raise the PSA blood test for a while, or cause a swollen, painful testicle.
Rare
BCG can spread into the bloodstream and cause high fever, low blood pressure and confusion. This is an emergency treated in the hospital with anti-tuberculosis medicines.
Rarely, BCG can infect the lungs, liver, kidneys, an artery graft or a joint replacement, sometimes months or years later. Tell doctors you have had BCG if you have an unexplained fever, cough or weight loss.
Rarely, ongoing inflammation scars the bladder so it holds much less urine.
Rare. Rash or swelling soon after treatment needs prompt care.
Call your care team or go to the emergency room if
- Fever of 101.3°F (38.5°C) or higher, or any fever that lasts more than 48 hours.
- Shaking chills, confusion, fast breathing, dizziness or feeling very unwell after a treatment: go to the emergency room and tell them you receive BCG in your bladder.
- Burning, urgency or frequent urination that lasts more than 2 to 3 days or keeps getting worse.
- Bright red urine, clots, or you cannot urinate.
- Painful swollen joints, red painful eyes, or a swollen painful testicle.
- A cough, night sweats or weight loss that does not go away, even months after treatment.
- Rash, hives or swelling of the face or lips: call 911 if you have trouble breathing.
Questions to ask your surgeon
- Why do you recommend BCG for me, and what is my risk group?
- How many treatments will I get, and for how long will maintenance last?
- When and how will we check whether it is working?
- What should I do in the bathroom after treatment, and do you want me to use bleach?
- Which of my medicines could affect BCG or make it less safe?
- Which side effects should I call about, and who do I call after hours?
- Is BCG in short supply right now, and would that change my dose or schedule?
- What happens if the cancer comes back during or after BCG?
- Would chemotherapy in the bladder be a reasonable choice for me instead?
- Are there clinical trials I could join?
- What precautions do you advise about sex during treatment?
Words you may hear
- BCG (Bacillus Calmette-Guérin)
- A weakened germ, related to the one that causes tuberculosis, used to stir up an immune attack on bladder cancer.
- Intravesical
- Inside the bladder. Intravesical treatments are placed into the bladder through a catheter.
- Induction
- The first course of BCG: one treatment a week for 6 weeks.
- Maintenance
- Sets of 3 weekly treatments given at set times after induction, for 1 to 3 years, to keep the effect going.
- Carcinoma in situ (CIS)
- Flat, high-grade cancer cells lying on the bladder lining.
- High-risk non-muscle-invasive bladder cancer
- Early bladder cancer that has not reached the muscle but has a high chance of coming back or growing deeper, such as high-grade, T1 or CIS.
- Cystoscopy
- Looking inside the bladder with a thin camera, usually in the office.
- Urine cytology
- A lab test that looks for cancer cells in the urine.
- Complete response
- No sign of cancer on cystoscopy, urine tests and biopsies after treatment.
- BCG-unresponsive
- High-grade cancer that persists or comes back despite an adequate course of BCG.
- Catheter
- A thin, soft tube passed through the urethra into the bladder.
- Immunotherapy
- Treatment that helps your own immune system find and attack cancer.
Common questions
Will BCG give me tuberculosis?
BCG is a weakened germ and almost never causes a serious infection when placed in the bladder. It can make a tuberculosis skin test turn positive, so tell anyone testing you that you have had BCG.
Can my family catch anything from me?
The risk is very low when you follow the bathroom and laundry steps you are given. Hugging, kissing, sharing meals and sleeping in the same bed are fine.
Why do the treatments feel worse each week?
BCG works by building up an immune reaction, so inflammation in the bladder grows as the course goes on. It usually settles within a few weeks after the course ends.
What if I cannot hold it for 2 hours?
Hold it as long as you comfortably can, then empty it using the safety steps and tell your team. Limiting fluids before the treatment usually makes holding easier next time.
What is the BCG shortage, and does it affect me?
For years, only one company has made BCG for bladder cancer in the United States, and supply has been tight at times. During shortages, national guidance lets teams give BCG first to the people who benefit most, sometimes at a lower dose or with a shorter maintenance schedule, and use chemotherapy in the bladder for others. Ask your team whether supply affects your plan.
Do I need to stop working during treatment?
Most people keep working. Many schedule treatments late in the week or in the afternoon so the worst of the irritation falls on a quieter evening or weekend.
Is BCG a kind of chemotherapy?
BCG is an immunotherapy: it works by rousing your immune system against the cancer. Chemotherapy in the bladder uses drugs that kill cancer cells directly. Both are given the same way, through a catheter.
Sources this page draws on
- American Urological Association and Society of Urologic Oncology, Diagnosis and Treatment of Non-Muscle Invasive Bladder Cancer: AUA/SUO Guideline
- European Association of Urology, EAU Guidelines on Non-muscle-invasive Bladder Cancer (TaT1 and CIS)
- SWOG (Southwest Oncology Group), Trial 8507: maintenance BCG for bladder cancer (Lamm and colleagues, Journal of Urology) (2000)
- American Cancer Society, Intravesical Therapy for Bladder Cancer
- National Cancer Institute, Bladder Cancer
- Urology Care Foundation, Bladder Cancer
Written November 2026. This page explains what usually happens. It is not medical advice and does not replace a conversation with your own surgeon, whose plan for you comes first.