How should I perform continuous bladder irrigation for a patient with chronic radiation cystitis and persistent brisk hematuria refractory to simple catheter drainage?

How to Perform Continuous Bladder Irrigation for Radiation-Induced Hemorrhagic Cystitis

For a patient with chronic radiation cystitis and persistent brisk hematuria refractory to simple catheter drainage, initiate continuous bladder irrigation (CBI) using a three-way Foley catheter with isotonic saline, evacuate clots, and prepare for endoscopic fulguration if bleeding persists beyond 24-48 hours. 1

Immediate Setup and Equipment

• Insert a large-bore three-way Foley catheter (22-24 Fr minimum) to accommodate both irrigation inflow and clot evacuation 2, 3
• Use 0.9% normal saline as the standard irrigation fluid, though be aware that prolonged use can cause hyperchloremic metabolic acidosis; consider switching to Ringer's lactate (109 mEq chloride vs 154 mEq in NS) if acidosis develops 4
• Connect the irrigation port to 3-liter bags of saline using gravity or an IV pump to control flow rate 5
• Attach drainage tubing to a large-capacity collection bag (2-5 liters) positioned below bladder level to ensure adequate gravity drainage 5

Irrigation Technique and Flow Management

• Titrate irrigation rate to maintain light pink or clear effluent—typically start at 300-500 mL/hour and adjust upward if clots persist 1, 3
• Monitor outflow continuously; if output significantly lags inflow, suspect catheter obstruction from clots and perform manual irrigation with a 60-mL catheter-tip syringe 2, 3
• Manually evacuate large clots by disconnecting the drainage port and using gentle suction with the syringe—avoid excessive force that could perforate the already friable bladder wall 2
• Continue CBI until effluent remains clear for 24 consecutive hours without new clot formation 3

Escalation for Refractory Bleeding

• If hematuria persists despite 24-48 hours of adequate CBI, proceed to cystoscopy with endoscopic fulguration of bleeding telangiectasias, which achieves approximately 75% complete response 1
• For bleeding that continues after fulguration, consider intravesical instillation of hemostatic agents (alum 1% solution at 300 mL/hour for 24-72 hours) 2, 3
• In life-threatening hemorrhage unresponsive to conservative measures, bilateral percutaneous nephrostomy for urinary diversion can help stop bleeding by decompressing the bladder and reducing vascular pressure 2

Critical Monitoring Parameters

• Assess fluid balance every 4-6 hours: measure total irrigation input versus drainage output to detect bladder perforation (output exceeds input) or absorption (input exceeds output) 4
• Monitor serum chloride and arterial blood gas if CBI continues beyond 48 hours, as normal saline absorption can cause H-NAGMA 4
• Check hemoglobin every 6-12 hours during active bleeding; transfuse to maintain Hgb >7-8 g/dL in stable patients 2, 3
• Perform urine culture before starting CBI to rule out infection, which must be treated concurrently 1

Special Considerations for Radiation Cystitis

• Recognize that radiation-damaged bladder tissue has poor vascularity and impaired healing, making it prone to perforation during aggressive manipulation 6, 1
• Chronic radiation cystitis typically peaks around 30 months post-treatment but can emerge 1-25 years after radiation exposure 6, 1
• This patient population has high morbidity: approximately 67% require emergency nephrostomy, and 22% mortality has been reported in severe cases despite aggressive treatment 2
• Exclude bladder malignancy with cystoscopy, as both cancer and radiation cystitis present with hematuria 1

Adjunctive Therapies During CBI

• Maintain aggressive hydration (150-200 mL/hour IV fluids) to dilute urine and reduce clot formation 6, 3
• Administer tranexamic acid 1 gram IV every 8 hours if systemic hemostatic support is needed, though evidence is limited in radiation cystitis 3
• If CBI must continue during hyperbaric oxygen therapy (HBOT), use the described monoplace chamber technique with IV pump-controlled inflow and extra-large drainage bags to prevent interruption of treatment 5

When to Abandon Conservative Management

• Surgical urinary diversion (ileal conduit) with or without cystectomy becomes necessary in approximately 10% of refractory cases when all conservative and endoscopic measures fail 1, 2
• Indicators for surgery include: persistent transfusion-dependent bleeding despite fulguration and intravesical agents, contracted non-functional bladder, or recurrent life-threatening hemorrhage 2, 3
• Cystectomy in irradiated tissue carries 42% severe complication rate and 16% mortality, making it truly a last resort 5