Treatment of Hemorrhagic Cystitis
Conservative management with hydration, forced diuresis, and frequent bladder emptying is the preferred initial approach for hemorrhagic cystitis, with interventions reserved for refractory cases using a stepwise escalation strategy. 1
Initial Assessment and Stabilization
When evaluating hemorrhagic cystitis, immediately check vital signs, hemoglobin, hematocrit, and coagulation parameters to assess bleeding severity 1. Perform urine analysis and culture to exclude infection as the underlying cause 1. A digital rectal examination should be completed to rule out other sources of hematuria 1.
First-Line Conservative Management
Hydration and Bladder Management
- Initiate aggressive hydration with 2-3 liters over 24 hours to dilute toxic metabolites in the urine 1
- Implement forced diuresis with >8 glasses of water daily 1
- Instruct patients to urinate frequently throughout the day, with particular emphasis on emptying the bladder immediately upon waking to prevent overnight dwelling of toxic metabolites 1
- Continuous bladder irrigation may be necessary for severe bleeding 2
Symptomatic Treatment
- Use non-steroidal anti-inflammatory drugs for pain management 1
- Prescribe anticholinergic agents such as oxybutynin for urinary symptoms 1
Anticoagulation Management
If the patient is on anticoagulation or antiplatelet therapy, specific adjustments are critical:
- Aspirin: Interrupt for 3 days following hemorrhage onset 1, 3
- Dual antiplatelet therapy: Continue the P2Y12 inhibitor while interrupting aspirin for 3 days 1, 3
- Anticoagulants: Restart between 7-15 days after hemorrhage onset, balancing recurrent bleeding risk against thromboembolism risk 3
- Earlier restart may be appropriate in patients with high thromboembolism risk 3
Escalation for Refractory Cases
When conservative measures fail, employ a stepwise approach:
Second-Line Interventions
- Bladder fulguration with continuous irrigation 2
- Botulinum toxin A injection into the detrusor muscle when drug therapy is ineffective 1
- Intravesical instillations (various agents including formalin) 4
Third-Line Interventions
- Hyperbaric oxygen therapy 5, 4
- Endoscopic procedures including electrical cautery, argon plasma coagulation, or laser coagulation 4
Last-Resort Measures
Prevention in Chemotherapy Patients
For patients receiving cyclophosphamide or ifosfamide, prevention is paramount:
- Administer mesna as IV bolus at 20% of the ifosfamide dose at the time of administration, followed by oral mesna at 40% of the ifosfamide dose at 2 and 6 hours after each dose 1
- If the patient vomits within 2 hours of oral mesna, repeat the dose or switch to IV mesna 1
- For high-dose cyclophosphamide (≥1500 mg/m²/day), use mesna plus saline diuresis 1
Monitoring Protocol
- Monitor urine output and appearance for signs of ongoing hematuria 1
- Perform monthly monitoring of urine for red blood cells in patients on cyclophosphamide 1
- Regularly assess renal function, especially in patients with pre-existing renal impairment 1
- Watch for signs of urinary tract infection, as hemorrhagic cystitis increases infection risk 1
Critical Pitfalls to Avoid
Avoid bladder biopsies unless findings strongly suggest bladder tumor, as they may precipitate complications and exacerbate bleeding 4. Do not perform aspiration, sclerotherapy, or laparoscopic procedures during active hemorrhage 1, 3. The pathogenesis involves urothelial cell death and smooth muscle dysfunction, making aggressive interventions during active bleeding particularly hazardous 6.
Imaging Considerations
Ultrasound is the first-line imaging modality, showing heterogeneous hyperechoic mobile material (clots) and thin septations 3. MRI is highly specific for diagnosis with characteristic findings on T1- and T2-weighted sequences 3. CT is generally unable to detect intracystic hemorrhage and should not be used for diagnosis, though it may detect rare cyst wall rupture 3.