What is the treatment for hemorrhagic cystitis?

Treatment of Hemorrhagic Cystitis

Treatment for hemorrhagic cystitis should follow a stepwise approach, beginning with conservative measures and escalating to more invasive interventions based on severity and response to treatment. 1

Etiology and Assessment

Hemorrhagic cystitis can result from multiple causes:

• Chemical exposure (cyclophosphamide, ifosfamide)
• Radiation therapy
• Viral infections
• Bacterial infections
• Idiopathic causes

Before initiating treatment, it's essential to:

• Perform urine analysis and urine culture to rule out infection
• Evaluate for primary bladder malignancy

Treatment Algorithm

First-Line Treatments (Mild to Moderate Cases)

1. Hydration and Clot Prevention

   • Aggressive intravenous fluid administration
   • Forced diuresis as clinically warranted
   • Frequent bladder emptying to reduce toxicity 1

2. Symptomatic Management

   • Non-steroidal anti-inflammatory drugs for pain and inflammation
   • Anticholinergic agents (e.g., oxybutynin) for bladder irritability 1
   • Analgesics such as phenazopyridine for urinary pain

3. Continuous Bladder Irrigation

   • Normal saline irrigation to prevent clot formation
   • Clot evacuation if needed 2, 3

Second-Line Treatments (Moderate to Severe Cases)

1. Hyperbaric Oxygen Therapy

   • Particularly effective for radiation-induced hemorrhagic cystitis 1, 4
   • Promotes tissue healing and neovascularization

2. Intravesical Instillations

   • Alum irrigation
   • Silver nitrate
   • Formalin (caution: can cause significant side effects) 5

3. Endoscopic Management

   • Transurethral fulguration of bleeding points 3
   • Laser coagulation for focal bleeding sites

Third-Line Treatments (Severe, Refractory Cases)

1. Interventional Radiology

   • Selective arterial embolization of vesical arteries 3
   • Consider when other treatments have failed and bleeding is life-threatening

2. Botulinum Toxin A Injection

   • Into the detrusor muscle when drug therapy is ineffective 1, 4
   • May help reduce bladder hyperactivity and associated bleeding

3. Surgical Options (Last Resort)

   • Urinary diversion with or without cystectomy 6, 3
   • Consider only in life-threatening, refractory cases unresponsive to all other treatments

Special Considerations

Cyclophosphamide-Induced Hemorrhagic Cystitis

• Administer mesna as a protective agent 1
• Maintain adequate hydration with forced diuresis
• Frequent bladder emptying to reduce contact time with toxic metabolites

Radiation-Induced Hemorrhagic Cystitis

• Often delayed onset (months to years after treatment)
• More likely to benefit from hyperbaric oxygen therapy
• May require more aggressive management due to underlying tissue damage 3

Monitoring and Follow-up

• Regular assessment of hematuria severity
• Monitoring of hemoglobin levels and transfusion requirements
• Evaluation of renal function, especially in severe cases

Pitfalls and Caveats

1. Delayed Recognition: Symptoms may be attributed to other causes, delaying appropriate treatment
2. Underestimation of Severity: What appears as mild hematuria can rapidly progress to life-threatening bleeding
3. Overreliance on Conservative Measures: Don't delay escalation of treatment when initial approaches fail
4. Infection Risk: Continuous bladder irrigation and catheterization increase infection risk; maintain vigilance for superimposed infections

Remember that hemorrhagic cystitis can be a persistent and recurrent condition requiring long-term management strategies and close follow-up.