What are the treatment options for hemorrhagic cystitis?

Treatment Options for Hemorrhagic Cystitis

The management of hemorrhagic cystitis requires a stepwise approach beginning with conservative measures and progressing to more invasive interventions based on severity, with hydration, forced diuresis, and frequent bladder emptying as first-line treatments to reduce bladder toxicity. 1

Etiology and Prevention

• Hemorrhagic cystitis commonly results from chemotherapy (particularly cyclophosphamide and ifosfamide), radiation therapy, viral infections, or chemical exposures 1, 2
• Prevention strategies include:
  • Mesna administration when using cyclophosphamide or ifosfamide to bind to the toxic metabolite acrolein 1
  • Adequate hydration (2-3 L in 24 hours) to dilute toxic metabolites 1
  • Frequent urination, especially upon waking, to prevent acrolein accumulation 1
  • Forced diuresis with >8 glasses of water daily and monthly urine monitoring for patients on cyclophosphamide 1

Treatment Algorithm

First-Line Approaches

• Hydration with forced diuresis and frequent bladder emptying to reduce bladder toxicity 1
• Non-steroidal anti-inflammatory drugs for pain management 1
• Anticholinergic agents such as oxybutynin for urinary symptoms 1
• Continuous bladder irrigation to prevent clot formation 2, 3

Second-Line Approaches

• Intravesical instillations:
  • Alum solution for hemostasis 2, 3
  • Cidofovir for BK virus-associated hemorrhagic cystitis (88% of patients showed clinical improvement) 4
  • Formalin instillation for severe cases (requires anesthesia) 5
• Botulinum toxin A injection into the detrusor muscle when drug therapy is ineffective 1
• Hyperbaric oxygen therapy for radiation-induced hemorrhagic cystitis 5

Advanced Interventions

• Cystoscopy with fulguration of bleeding points 2, 3
• Selective arterial embolization for intractable bleeding 2, 3, 5
• Surgical options for severe refractory cases:
  • Urinary diversion 2
  • Cystectomy with ileal conduit as a last resort for life-threatening hemorrhage 6

Management Based on Specific Causes

Chemotherapy-Induced Hemorrhagic Cystitis

• For ifosfamide-induced cystitis: mesna administration as an IV bolus at 20% of the ifosfamide dose at administration, followed by oral mesna at 40% of the ifosfamide dose at 2 and 6 hours after each ifosfamide dose 1
• Patients who vomit within 2 hours of taking oral mesna should repeat the dose or receive IV mesna 1

Radiation-Induced Hemorrhagic Cystitis

• Hyperbaric oxygen therapy has shown efficacy 5
• Intravesical instillations of hyaluronic acid may help repair damaged urothelium 3

Viral-Associated Hemorrhagic Cystitis

• Intravesical cidofovir for BK virus-associated hemorrhagic cystitis, particularly in hematopoietic stem cell transplant patients 4
• Supportive care with bladder irrigation and blood transfusions as needed 4

Intracystic Hemorrhage

• Conservative management is preferred during active hemorrhage 1
• Avoid interventions such as aspiration or laparoscopic procedures during active bleeding 1

Monitoring and Follow-up

• Regular assessment of urine output and appearance for signs of hematuria 1
• Monitoring of renal function, especially in patients with pre-existing renal impairment 1
• Surveillance for signs of infection, as hemorrhagic cystitis can predispose to urinary tract infections 1
• Monthly monitoring of urine for red blood cells in patients on cyclophosphamide 1

Special Considerations

• In patients with hematologic malignancies or post-transplant, viral etiologies (particularly BK virus) should be considered 4
• Hemorrhagic cystitis can be life-threatening, with reported mortality in severe cases, emphasizing the need for prompt and effective management 5
• Treatment should be escalated based on severity of bleeding and patient response to previous interventions 2, 3