Cystoscopic Findings in Chronic Radiation Cystitis
Cystoscopy in chronic radiation cystitis characteristically reveals a pale, frosted bladder mucosa with scattered telangiectasias and sometimes well-defined torpid ulcerations. 1
Classic Endoscopic Appearance
The hallmark cystoscopic features include:
Pale, frosted mucosa – The bladder lining appears blanched and has a characteristic frosted or whitish appearance due to underlying vascular damage and fibrosis 1
Scattered telangiectasias – Multiple dilated blood vessels (telangiectasias) are visible throughout the bladder wall, representing the neovascularization that occurs after radiation-induced vascular endothelial damage 2, 1
Torpid ulcerations – Well-defined, chronic ulcerations may be present that are slow to heal due to the poor vascularity and impaired wound healing in radiation-damaged tissue 3, 1
Pathophysiologic Basis of Findings
These cystoscopic changes reflect the underlying pathophysiology:
Vascular endothelial cell damage develops with a latency period of 1 to 25 years after radiation exposure, causing the characteristic telangiectasias and bleeding 2
Reduced bladder capacity results from damage to bladder vasculature and smooth muscle fibers, leading to edema, cell death, and progressive fibrosis 2
Poor tissue vascularity makes the bladder mucosa appear pale and increases the risk of perforation during aggressive manipulation 3
Clinical Context and Timing
Chronic radiation cystitis symptoms typically become apparent 8-12 months after completing radiation therapy, though the latency period can extend from 1 to 25 years 2, 3
Cystoscopy is indicated when patients present with hematuria, urinary frequency, urgency, nocturia, or pelvic pain following pelvic radiotherapy 2, 1
The diagnosis is usually straightforward given the patient's history of pelvic irradiation combined with these characteristic endoscopic findings 1
Critical Diagnostic Considerations
Always perform flexible sigmoidoscopy or colonoscopy to exclude alternative pathology, particularly bladder malignancy, as both conditions can present with similar symptoms of hematuria 3
Urine analysis and culture must be obtained to rule out urinary tract infection before attributing symptoms solely to radiation cystitis 3
Avoid biopsy unless a neoplastic process is strongly suspected, as the radiation-damaged tissue has poor healing capacity and increased perforation risk 3
Severity Assessment
The extent of telangiectasias and ulceration on cystoscopy helps stratify disease severity:
Grade 1/2 disease shows mild mucosal changes with scattered telangiectasias 2
Severe disease demonstrates extensive telangiectasias, significant ulceration, and contracted bladder capacity, often requiring more aggressive intervention 4, 1
Approximately 5-9% of patients receiving pelvic radiotherapy develop chronic hemorrhagic cystitis requiring intervention 2, 3