Treatment of Hemorrhagic Cystitis
For hemorrhagic cystitis, begin with hydration and bladder irrigation, then escalate through anticholinergics, endoscopic fulguration, hyperbaric oxygen, and intravesical therapies, reserving surgery for refractory cases. 1, 2
Initial Management and Resuscitation
- Immediate hydration with forced diuresis (2-3 L in 24 hours) is the cornerstone of initial therapy to dilute toxic metabolites and reduce bladder toxicity 2, 3
- Continuous bladder irrigation with normal saline and clot evacuation should be initiated for active bleeding 1, 4, 3
- Check vital signs, hemoglobin, hematocrit, and coagulation parameters to assess bleeding severity 2
- Perform urine analysis and culture to exclude infection as a contributing cause 1, 2
- Ensure frequent bladder emptying, especially upon waking, to prevent accumulation of toxic metabolites 2
Stepwise Treatment Algorithm
First-Line Medical Management
- Non-steroidal anti-inflammatory drugs (NSAIDs) for pain control 1, 2
- Anticholinergic agents such as oxybutynin for urinary frequency, urgency, and bladder spasm symptoms 1, 2
- Analgesics such as phenazopyridine for dysuria 1
- These medications can typically be discontinued as symptoms improve, as they are generally self-limited 1
Second-Line Interventions
- Endoscopic fulguration for bleeding control when conservative measures fail 1, 4
- Botulinum toxin A injection into the detrusor muscle when drug therapy proves ineffective 1, 2
- Hyperbaric oxygen therapy is an established option for radiation-induced hemorrhagic cystitis, with multiple studies supporting its efficacy 3, 5
Third-Line Intravesical Therapies
- Various intravesical instillations have been described, though evidence is limited and heterogeneous 1, 4, 3
- Intravesical silver nitrate has shown poor efficacy in recent studies, with 100% of patients requiring additional interventions despite treatment 6
- Emerging therapies such as liposomal tacrolimus show promise but require further research 5
Surgical Options for Refractory Disease
- Arterial embolization can be considered for persistent bleeding 4
- Urinary diversion or cystectomy should be evaluated only in cases of truly refractory disease, as these carry significant morbidity and mortality 1, 4, 7
- Simple cystectomy with ileal conduit has been successful in critical cases with multiple complications, though this represents an extreme measure 7
Prevention Strategies (When Applicable)
For patients receiving cyclophosphamide or ifosfamide chemotherapy:
- Mesna administration is essential to bind the toxic metabolite acrolein 2
- For ifosfamide specifically: give mesna as IV bolus at 20% of the ifosfamide dose at time of administration, followed by oral mesna at 40% of the ifosfamide dose at 2 and 6 hours after each dose 2
- Patients who vomit within 2 hours of oral mesna must repeat the dose or receive IV mesna 2
- Monthly monitoring of urine for red blood cells is recommended for patients on cyclophosphamide 2
Critical Pitfalls to Avoid
- Do not perform aspiration or laparoscopic procedures during active hemorrhage—conservative management is preferred for intracystic hemorrhage 2
- Exclude bladder malignancy and recurrent disease before attributing bleeding to radiation or chemotherapy effects 1
- Intravesical silver nitrate has limited efficacy despite being well-tolerated, with recent evidence showing 100% failure rate for bleeding control 6
- Surgical interventions carry substantial morbidity and mortality and should only be considered after exhausting less invasive options 4, 3
Monitoring Requirements
- Monitor urine output and appearance continuously for signs of ongoing or worsening hematuria 2
- Assess renal function regularly, particularly in patients with pre-existing renal impairment 2
- Watch for signs of urinary tract infection, as hemorrhagic cystitis predisposes to secondary infections 2
- For radiation cystitis, bladder bleeding may peak around 30 months post-treatment, after which prevalence rates typically return to baseline 1