What are the treatment options for radiation cystitis?

Treatment Options for Radiation Cystitis

Hyperbaric oxygen therapy should be considered the primary treatment for radiation cystitis, particularly for hemorrhagic cases that don't respond to conservative management, as it addresses the underlying pathophysiology and has demonstrated success rates of 60-92% in resolving symptoms. 1

Understanding Radiation Cystitis

Radiation cystitis is a common complication following pelvic radiotherapy that manifests in two forms:

• Acute radiation cystitis: Occurs during or shortly after radiation treatment, typically self-limiting and managed conservatively
• Late radiation cystitis: Develops 6 months to 20 years after radiation therapy, with hematuria as the main symptom ranging from mild to severe, life-threatening hemorrhage 2

The pathophysiology involves radiation-induced damage to bladder vasculature and smooth muscle fibers, resulting in:

• Vascular endothelial cell damage
• Obliterative endarteritis leading to tissue hypoxia
• Edema, cell death, and fibrosis
• Reduced bladder capacity 1

Treatment Algorithm

First-Line Management (Acute/Mild Cases)

1. Conservative measures:
   • Intravenous fluid replacement
   • Blood transfusion if indicated
   • Transurethral catheterization with bladder washout and irrigation 2
   • Non-steroidal anti-inflammatory drugs
   • Anticholinergic agents (e.g., oxybutynin)
   • Analgesics (e.g., phenazopyridine) 1

Second-Line Management (Persistent Cases)

1. Pharmacological options:

   • Oral or parenteral agents:
     • Conjugated estrogens
     • Pentosan polysulfate
     • WF10 2, 3

2. Intravesical instillations:

   • Aluminum
   • Placental extract
   • Prostaglandins
   • Formalin (more aggressive option) 2

Third-Line Management (Refractory Cases)

1. Hyperbaric oxygen therapy (HBOT):

   • Administration of 100% oxygen at 2.0-2.5 atmospheres for 90 minutes, 5 days a week
   • Average of 31-40 treatments required
   • Success rates of 60-92% reported
   • Induces neo-vascularization, tissue re-oxygenation, collagen neo-deposition and fibroblast proliferation 1, 2, 4, 5

2. Endoscopic procedures:

   • Cystoscopy with laser fulguration
   • Electrocoagulation of bleeding points
   • Argon plasma coagulation (resolves 80-90% of cases)
   • Potassium titanyl phosphate or YAG lasers for superficial injuries 1, 2, 3

3. Other interventional options:

   • Botulinum toxin A injection in the bladder wall for irritative symptoms 1, 2
   • Radio-frequency ablation (2-3 sessions) 1
   • Cryoablation (excellent results but not widely used) 1

Fourth-Line Management (Severe Refractory Cases)

1. Vascular interventions:

   • Selective embolization of internal iliac arteries
   • Ligation of internal iliac arteries 2

2. Surgical options (last resort):

   • Urinary diversion via percutaneous nephrostomy
   • Intestinal conduit with or without cystectomy 2
   • For ureteral strictures: endoscopy or open surgery including percutaneous nephrostomy, ureteral stent, or ileal ureteral substitution 1

Clinical Considerations and Caveats

Timing of Intervention

• Early application of hyperbaric oxygen is associated with earlier resolution of hemorrhagic cystitis 4
• Delaying treatment of ureteral blockage increases risk of serious long-term morbidity including infections, kidney damage, and hypertension 1

Long-term Outcomes

• While HBOT produces good short-term benefits, long-term recurrence may occur in some patients (5 of 11 patients in one study) 6
• Bladder cystitis and bleeding may reach peak prevalence at about 30 months, after which rates may fall to baseline, indicating healing 1

Risk Factors for Severe Radiation Cystitis

• History of abdominal surgery
• Pelvic inflammatory disease
• Hypertension
• Diabetes mellitus
• Smoking
• Older age
• Obesity and overweight 1

Important Precautions

• Avoid bladder biopsies unless findings suggest a bladder tumor, as they may precipitate complications 3
• Manage patients conservatively initially and intervene only when necessary with the option least likely to exacerbate the cystitis 3
• Always rule out infection and primary bladder malignancy before attributing symptoms to radiation cystitis 1