What are the treatment options for Radiation-induced cystitis (Radiation-induced hemorrhagic cystitis)?

From the Guidelines

Radiation-induced cystitis treatment should prioritize a multi-faceted approach, including hydration, non-steroidal anti-inflammatory drugs, anticholinergic agents, and analgesics for mild cases, while hyperbaric oxygen, clot evacuation, endoscopic fulguration, and bladder irrigation are considered for more severe cases, as recommended by the 2024 position paper on radiotherapy-related toxicities in gynecological malignancies 1.

Treatment Options

• For acute symptoms, the workup should include urine analysis and urine culture, followed by management with non-steroidal anti-inflammatory drugs, anticholinergic agents such as oxybutynin, or analgesics such as phenazopyridine, as suggested by the 2024 study 1.
• Botulinum toxin A injection into the detrusor muscle may be used when drug therapy is ineffective, as mentioned in the same study 1.
• Treatment for hemorrhagic cystitis includes hydration, hyperbaric oxygen, clot evacuation, endoscopic fulguration, and bladder irrigation with a variety of substances, as outlined in the 2024 position paper 1.
• Surgery should be evaluated in case of refractory disease, and infection and primary bladder malignancy must also be evaluated, as recommended by the same study 1.

Key Considerations

• Symptoms are generally self-limited, and drugs can be discontinued as symptoms improve, as noted in the 2024 study 1.
• The treatment approach should be individualized based on the severity of the condition and the patient's response to initial management, considering the lack of guidelines for managing urinary toxicity, as highlighted in the 2024 position paper 1.

From the Research

Treatment Options for Radiation-Induced Cystitis

The treatment options for radiation-induced cystitis can be categorized into conservative management, oral or parenteral agents, endoscopic procedures, and more aggressive treatments.

• Conservative management includes intravenous fluid replacement, blood transfusion if indicated, and transurethral catheterization with bladder washout and irrigation 2.
• Oral or parenteral agents that can be used to control hematuria include conjugated estrogens, pentosan polysulfate, or WF10 2, 3.
• Endoscopic procedures such as cystoscopy with laser fulguration or electrocoagulation of bleeding points can be effective in managing radiation-induced cystitis 2.
• Intravesical instillation of aluminum, placental extract, prostaglandins, or formalin can also be used to control hematuria 2, 3.
• Hyperbaric oxygen therapy (HBOT) has been shown to be effective in treating radiation-induced hemorrhagic cystitis, with reported success rates ranging from 60% to 92% 2, 4, 5, 6.
• More aggressive treatment options include selective embolization or ligation of the internal iliac arteries, and surgical options such as urinary diversion by percutaneous nephrostomy or intestinal conduit, with or without cystectomy 2.

Hyperbaric Oxygen Therapy

Hyperbaric oxygen therapy is a widely accepted treatment option for radiation-induced hemorrhagic cystitis.

• Studies have shown that HBOT can improve angiogenesis and promote healing in radiation-injured tissue, including the bladder 4, 5, 6.
• The efficacy of HBOT for treatment of hemorrhagic cystitis has been assessed in several studies, with reported success rates ranging from 64% to 86% 4, 5, 6.
• HBOT is generally well-tolerated, even in patients debilitated by advanced cancer and blood loss 4, 6.

Other Considerations

• Bladder biopsies should be avoided unless findings suggest a bladder tumor, as they may precipitate a complication 3.
• It is generally recommended to manage patients conservatively and intervene only when necessary with the option least likely to exacerbate the cystitis 3.