From the Guidelines
Hemorrhagic cystitis should be diagnosed and treated with a focus on maintaining adequate hydration, pain management, and addressing the underlying cause, with the most recent and highest quality study recommending forced diuresis and monthly monitoring of urine for red blood cells to prevent clinically significant hemorrhagic cystitis in patients treated with cyclophosphamide 1.
Diagnosis and Treatment
Hemorrhagic cystitis is inflammation of the bladder characterized by blood in the urine and painful urination. The diagnosis is based on the presence of blood in the urine, painful urination, and other symptoms such as frequent urination and urgency.
Causes and Prevention
The causes of hemorrhagic cystitis include viral infections (BK virus, adenovirus), radiation therapy, chemotherapy agents, and bacterial infections. To prevent hemorrhagic cystitis, patients should maintain adequate hydration, urinate frequently, and avoid exposure to toxic substances.
Treatment Options
Treatment depends on the cause but typically includes:
- Hydration: increased fluid intake (2-3 liters daily) to dilute urine and reduce irritation
- Pain management: NSAIDs like ibuprofen (400-600mg every 6-8 hours) or prescription phenazopyridine (Pyridium, 100-200mg three times daily) for urinary tract analgesia
- Addressing the underlying cause:
- Chemotherapy agents like cyclophosphamide: mesna (sodium 2-mercaptoethanesulfonate) given prophylactically to bind toxic metabolites
- Bacterial infections: appropriate antibiotics based on culture results
- Radiation-induced cases: pentosan polysulfate sodium (100mg three times daily) to repair bladder lining
- Severe cases may require bladder irrigation with saline solution, instillation of alum or silver nitrate to control bleeding, or hyperbaric oxygen therapy. As recommended by the study published in the American Journal of Respiratory and Critical Care Medicine, forced diuresis, > 8 glasses (8 oz. each) of water daily, and monthly monitoring of the urine for red blood cells or other abnormality is recommended in an attempt to prevent clinically significant hemorrhagic cystitis in patients treated with cyclophosphamide 1.
From the Research
Diagnosis of Hemorrhagic Cystitis
- Hemorrhagic cystitis is characterized by persistent hematuria and lower urinary tract symptoms following radiotherapy or chemotherapy 2
- The condition can be diagnosed using cystoscopy and biopsy to confirm the presence of radiation-induced injury to the bladder 3
- A literature review of 41 articles identified a broad differential diagnosis for intractable hemorrhagic cystitis, including infection, chemical exposure, malignancy, nephropathy, trauma, radiation therapy, and idiopathic etiology 4
Treatment Options for Hemorrhagic Cystitis
- Various palliative treatments, including instillation of alum, silver nitrate, and formalin, may be used to alleviate patient symptoms 3
- Hyperbaric oxygen therapy has been shown to be effective in treating radiation-induced hemorrhagic cystitis, with 27% of patients experiencing complete and durable resolution of symptoms 3
- Other treatment options include fulguration, botulinum toxin A, and intravesical therapies, which have demonstrated short-term efficacy in cohort studies 2
- Novel agents, such as liposomal tacrolimus, are promising targets for further research 2
- A stepwise treatment approach has been proposed, ranging from conservative strategies (bladder fulguration and continuous irrigation) to more extreme and morbid therapies (intravesical instillations, embolization, and urinary diversion) 4
- Prevention of hemorrhagic cystitis is essential, but not always effective, and various treatment options are available, including clot extraction, continuous bladder irrigation, and salvage surgery 5, 6
Etiology of Hemorrhagic Cystitis
- The two predominant causes of hemorrhagic cystitis are chemical and irradiation 5
- Chemical compounds, such as oxaphosphorines (cyclophosphamide, ifosfamide), can cause hemorrhagic cystitis 5
- Infectious causes, such as bacterial, fungal, parasitic, or viral infections, can also lead to hemorrhagic cystitis 5, 6
- Hemorrhagic cystitis can occur in the context of a systemic disease or may be isolated and idiopathic 5