What are the management options for radiation-induced cystitis (RT cystitis)?

Management of Radiation-Induced Cystitis

For acute radiation cystitis, start with hydration, NSAIDs, and anticholinergics; for chronic hemorrhagic cystitis, hyperbaric oxygen therapy is the first-line treatment after conservative measures fail, with endoscopic interventions and intravesical therapies reserved for refractory cases. 1, 2

Initial Assessment and Conservative Management

Acute Radiation Cystitis (During or Within Weeks of Treatment)

• Acute symptoms (dysuria, frequency, nocturia, hesitancy) typically occur after 20 Gy to the bladder and resolve 2-3 weeks after treatment completion 3
• Rule out urinary tract infection with urine analysis and culture 1, 2
• Initiate aggressive hydration with goal of 2-3 L in 24 hours to dilute toxic metabolites 2
• Prescribe NSAIDs for pain control and dysuria 1, 2
• Add anticholinergic agents (oxybutynin) for urinary frequency, urgency, and bladder spasm 1, 2
• Consider phenazopyridine for symptomatic relief of dysuria 2

Chronic Radiation Cystitis (6 Months to 20 Years Post-Treatment)

• Chronic symptoms result from vascular endothelial cell damage with latency period of 1-25 years 3
• Hemorrhagic cystitis occurs in 5-9% of patients and represents the most serious manifestation 3
• Check vital signs, hemoglobin, hematocrit, and coagulation parameters to assess bleeding severity 2
• Rule out infection and primary bladder malignancy before attributing symptoms to radiation 1

Management Algorithm for Hemorrhagic Cystitis

Step 1: Emergency Stabilization (If Active Bleeding)

• Initiate continuous bladder irrigation with normal saline 2, 4
• Perform transurethral catheterization with clot evacuation 2, 4
• Provide intravenous fluid replacement and blood transfusion if indicated 4

Step 2: First-Line Definitive Treatment - Hyperbaric Oxygen Therapy

Hyperbaric oxygen therapy should be the primary treatment for radiation-induced hemorrhagic cystitis after conservative measures fail, with success rates of 86-92% and excellent long-term outcomes. 5, 6, 7

• Administer 100% oxygen at 2-2.5 atmospheres of pressure 6, 7
• Typical protocol: 80-90 minutes per session for average of 30-40 sessions 5, 6, 7
• Earlier initiation after first hematuria episode correlates with better response rates and lower recurrence 7
• Complete resolution or marked improvement occurs in 86-92% of patients 5, 6
• Long-term follow-up shows 24.7% recurrence rate at median 63 months, but overall sustained benefit 7
• Well tolerated with minimal complications (barotrauma requiring myringotomy in <3% of cases) 6
• Mechanism: induces neo-vascularization, tissue re-oxygenation, collagen neo-deposition, and fibroblast proliferation 3

Step 3: Endoscopic Interventions (If HBO Unavailable or Fails)

• Endoscopic fulguration or laser coagulation of bleeding points 1, 4
• Cystoscopy with electrocoagulation can be effective for localized bleeding 4
• Note: Argon plasma coagulation has serious complication rates up to 26% in radiation-damaged tissue and should be used with extreme caution 3

Step 4: Intravesical Therapies (For Refractory Cases)

• Intravesical formalin instillation (effective but potentially morbid) 4, 8
• Intravesical aluminum instillation 4
• Intravesical silver nitrate 8
• These represent last-line medical options before surgery 8

Step 5: Systemic Medical Therapies (Adjunctive or When Other Options Unavailable)

• Conjugated estrogens (oral or parenteral) 4
• Pentosan polysulfate 4
• WF10 4

Step 6: Interventional Procedures (For Severe Refractory Disease)

• Botulinum toxin A injection into detrusor muscle for persistent irritative symptoms when drug therapy fails 3, 1
• Selective embolization or ligation of internal iliac arteries for uncontrolled bleeding 4

Step 7: Surgical Management (Last Resort)

• Percutaneous nephrostomy for upper tract decompression 3, 1
• Ureteral stent placement 3, 1
• Ileal ureteral substitution 3, 1
• Urinary diversion with intestinal conduit with or without cystectomy 4
• Surgery is reserved for refractory disease due to poor vascularity and wound healing in irradiated tissues 1

Risk Factors to Identify

Patients at higher risk for severe late genitourinary toxicity include those with: 3

• History of abdominal surgery or pelvic inflammatory disease
• Hypertension, diabetes mellitus, or active smoking
• Older age (higher incontinence risk)
• Obesity or overweight status
• Pre-existing hydronephrosis at diagnosis (11.5% vs 4.8% ureteral stricture risk at 5 years)

Follow-Up and Monitoring

• Bladder cystitis and bleeding typically peak at approximately 30 months post-radiation, then rates fall to baseline 1, 2
• Clinical examination and accurate history should guide instrumental testing for urinary tract dysfunction 3, 1
• Monitor renal function regularly, especially in patients with pre-existing renal impairment 1, 2
• Watch for signs of urinary tract infection, as hemorrhagic cystitis predisposes to secondary infections 2
• Monitor urine output and appearance continuously for signs of ongoing or worsening hematuria 2

Critical Pitfalls to Avoid

• Do not use argon plasma coagulation without extreme caution - serious complication rates up to 26% include deep ulceration, bleeding, fistulation, perforation, stricture formation, and severe chronic pain in chronically ischemic radiation-damaged tissues 3
• Do not delay treatment of hemorrhagic cystitis - earlier HBO intervention correlates with better outcomes 7
• Do not attribute all urinary symptoms to radiation without ruling out infection and malignancy 1
• Do not proceed directly to aggressive interventions without attempting conservative management and HBO therapy first 8