Haemorrhagic & radiation cystitis

Haemorrhagic cystitis – diffuse inflammation and bleeding from bladder mucosa with damaged urothelium

Characterised by haematuria and storage symptoms. May be acute or chronic.

Possible causes of haemorrhagic cystitis:

Radiation cystitis

Therapeutic ionising radiation works by inducing double strand DNA breaks.

Normal vascular endothelium is damaged by radiation, causing inflammation, fibrosis and ischaemia, resulting in obliterative arteritis.

Local vascular compromise predisposes to infection and poor healing.
Submucosa may become fibrotic and less compliant -> angiogenesis and new mucosal vessels which are fragile and prone to bleeding.
Damage to the GAG layer – permeability results in chronic inflammation and lack of normal defence layer.

Basic management:

3 way catheter with manual washout of clots and continuous irrigation
Identification and correction of coagulopathy – cessation or reversal of anticoagulation
Identification and treatment of underlying causes if possible (UTIs etc)
Supportive cares
- Transfusion if needed
- Rehydration, analgesia

Still needs work up when bleeding settles with cystoscopy and upper tract imaging.

Advanced management:

Alum

Administered in 0.5 – 1 % solution by continuous irrigation
50 g Alum in 5 L water = 1 %
Acts as an astringent – precipitates surface proteins and stimulates vasoconstriction and reduction in vessel permeability
Variable success
Systemic absorption is low but not zero – theoretical aluminium toxicity causing mental status changes, more likely in renal compromise
Bladder spasms very common

Formalin

Causes precipitation of proteins, and occludes and fixates the bleeding telangiectasia
Higher rates of success but significant pain – usually given under GA over 15 minutes, with traction of catheter to avoid urethral exposure
Significant potential local complications – fibrosis of bladder, severely reduced capacity, reflux and ureteric stricturing – consider cystogram prior to exclude reflux and any bladder perforation prior to instillation

Other options

Aminocaproic acid – synthetic lysine which competitively inhibits plasminogen, decreasing fibrinolysis – can be given orally or intravesically – all case reports from decades ago. Risks of VTE.
Silver nitrate – mixed with water (will precipitate in saline), converts to nitric acid and chemically cauterises urothelium

Hyperbaric oxygen

Promotes capillary angiogenesis and neovascularisation and healing by increasing oxygen uptake in damaged or radiated tissue
Administration of 100 % oxygen at a pressure of 2 – 3 atm for 1-2 hours
- 20 – 40 daily sessions
Must be stable enough to undergo the treatment in a chamber alone
Good reported short-medium term success 80 – 90 %, but dubious long term success (5 year complete response only 27 %.

Last resort options: