What is the treatment for hemorrhagic cystitis?

Treatment of Hemorrhagic Cystitis

The treatment of hemorrhagic cystitis follows a stepwise approach beginning with hydration and bladder irrigation, progressing through intravesical therapies and hyperbaric oxygen if needed, with surgical intervention reserved as a last resort.

Initial Stabilization and Assessment

Immediate resuscitation with bladder washout, clot evacuation, and continuous bladder irrigation forms the foundation of acute management 1. Check vital signs, hemoglobin, hematocrit, and coagulation parameters to evaluate bleeding severity 2. Perform urine analysis and culture to rule out infection as a contributing cause 2. A focused history and physical examination, including digital rectal examination, should identify other potential causes of hematuria 2.

Etiology-Specific Considerations

The underlying cause significantly influences treatment strategy:

Chemotherapy-Induced (Prevention and Early Treatment)

• Mesna administration is essential for cyclophosphamide or ifosfamide therapy 2
• For ifosfamide: 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 dose 2
• If vomiting occurs within 2 hours of oral mesna, repeat the dose or switch to IV 2
• Maintain aggressive hydration (2-3 L in 24 hours) to dilute toxic metabolites 2
• Instruct patients to urinate frequently, especially immediately upon waking, to prevent acrolein accumulation overnight 2

Radiation-Induced

• Standard initial management involves resuscitation, bladder washout with clot evacuation, and continuous bladder irrigation 1
• Avoid bladder biopsies unless malignancy is suspected, as they may precipitate complications 3

Stepwise Treatment Algorithm

First-Line Conservative Management

• Hydration with forced diuresis and frequent bladder emptying 2
• Continuous bladder irrigation with three-way catheter for clot evacuation 4, 1
• NSAIDs for pain management 2
• Anticholinergic agents (oxybutynin) for urinary symptoms 2

Second-Line Interventions (When Conservative Measures Fail)

• Bladder fulguration with electrocautery or laser ablation 4, 1
• Hyperbaric oxygen therapy - particularly effective for radiation cystitis with evidence from 7 studies 1, 5
• Intravesical therapies including various agents studied in 10 different trials 1
• Botulinum toxin A injection into the detrusor muscle when drug therapy is ineffective 2

Third-Line Options (Refractory Cases)

• Intravesical instillations with various agents 4
• Arterial embolization 4
• Systemic medical therapies 1

Last Resort (Severe, Life-Threatening Cases)

• Urinary diversion - associated with significant morbidity and mortality 4, 1
• Definitive surgical treatment should be avoided when possible due to high complication rates 1

Anticoagulation Management

For patients on antiplatelet or anticoagulation therapy:

• Interrupt aspirin for 3 days following hemorrhage onset 6
• For dual antiplatelet therapy, continue P2Y12 inhibitor while interrupting aspirin 6
• Consider restarting anticoagulants between 7-15 days after hemorrhage onset, with earlier restart for high thromboembolism risk patients 6

Monitoring Requirements

• Monitor urine output and appearance for signs of ongoing hematuria 2
• Regular assessment of renal function, especially in patients with pre-existing renal impairment 2
• Watch for signs of infection, as hemorrhagic cystitis predisposes to UTIs 2
• For patients on cyclophosphamide, perform monthly urine monitoring for red blood cells 2

Critical Pitfalls to Avoid

Conservative management is strongly preferred for intracystic hemorrhage - avoid aspiration or laparoscopic procedures during active hemorrhage 2, 6. This is a common mistake that can worsen bleeding and increase morbidity. Bladder biopsies should be avoided in radiation cystitis unless tumor is suspected, as they may exacerbate the condition 3. More aggressive surgical measures should only be employed when conservative approaches fail 3.

The evidence base for hemorrhagic cystitis treatment consists primarily of small heterogeneous cohort studies with variable follow-up 1. No single therapy is uniformly effective 7, making the stepwise approach essential. The pathogenesis involves acrolein toxicity in chemotherapy cases and fibrosis/vascular remodeling in radiation cases 5, which explains why prevention with mesna is more effective than treatment of established disease.