Hemorrhagic cystitis (HC) is inflammation and irritation of the bladder lining resulting in bleeding into the urine. This serious complication ranges from mild blood loss to life-threatening hemorrhage with clot formation. Management focuses on stopping the bleeding, relieving severe symptoms, and preserving bladder function. Treatment follows a methodical, escalating approach, starting with non-invasive supportive measures and progressing to specialized interventional and surgical procedures.
Defining the Causes and Clinical Presentation
Hemorrhagic cystitis most commonly arises as a complication of cancer treatments that damage the bladder’s inner layer (urothelium). The primary chemical culprits are oxazaphosphorine chemotherapy agents (e.g., cyclophosphamide and ifosfamide), whose toxic metabolite, acrolein, irritates the bladder wall. Pelvic radiation therapy is the other major cause, leading to chronic damage, reduced blood flow, and subsequent bleeding. Viral infections, particularly the BK virus in immunocompromised patients, can also trigger this condition.
Clinical presentation varies widely, from mild irritation to a severe medical emergency. Patients typically experience hematuria, which can be microscopic or gross (visible). Irritative lower urinary tract symptoms, including painful urination (dysuria), increased frequency, and urgency, are also prominent. Severity is graded based on the extent of bleeding, with the most severe cases involving massive hemorrhage and large blood clots that obstruct urine outflow.
First-Line Supportive Care and Symptom Relief
Initial management focuses on stabilizing the patient and mitigating symptoms using non-invasive systemic methods. Aggressive systemic hydration is paramount, often requiring intravenous fluids to induce a forced diuresis. The goal is a urine output of approximately 2 to 3 liters per day. This high fluid intake dilutes toxic agents and mechanically flushes the bladder to prevent clot formation.
Symptom relief is also important, as bladder irritation and spasms cause significant discomfort. Antispasmodic medications are administered to calm involuntary bladder contractions triggered by inflammation and blood clots. Analgesics manage pain and discomfort. Addressing underlying issues, such as a urinary tract infection, with appropriate antibiotics or antivirals (like cidofovir for BK virus), is a standard part of this initial supportive protocol.
Interventions for Direct Hemorrhage Control
If supportive care fails to halt the bleeding, direct interventions targeting the hemorrhage are initiated. The first procedural step is often placing a large-bore, three-way catheter for Continuous Bladder Irrigation (CBI) with normal saline. This constant fluid flow washes out existing blood clots and prevents new ones from forming, maintaining urinary drainage and averting clot retention.
If bleeding persists, intravesical instillation of specialized agents is employed, delivered directly into the bladder lumen. Aluminum potassium sulfate (alum) is frequently used, typically administered as a 1% solution. Alum acts as a chemical astringent, causing protein precipitation and local vasoconstriction to seal off small bleeding vessels. Another option is silver nitrate (0.5% to 1%), which chemically cauterizes the urothelium. Silver nitrate requires caution and assessment to ensure no urine reflux into the kidneys, which could cause upper urinary tract damage.
Managing Severe and Persistent Cases
For refractory HC that fails to respond to maximal supportive care and intravesical astringents, more invasive procedures are necessary. Cystoscopy and clot evacuation are performed under anesthesia to allow for direct visualization and removal of large, obstructing clots. This procedure may be combined with fulguration, using electrocautery or laser to seal discrete bleeding vessels within the bladder wall.
Hyperbaric Oxygen Therapy (HBOT) offers a non-surgical alternative, especially for radiation-induced cases. HBOT delivers 100% oxygen at high pressure (typically 2.0 to 2.5 atmospheres). This significantly increases bloodstream oxygen concentration, promoting neoangiogenesis and healing in the chronically ischemic bladder tissue. Treatment usually involves around 40 sessions over several weeks.
Last-Line Interventions
A potent chemical sealant, intravesical formalin, is reserved as a last-line intravesical measure due to its caustic effects and risk of long-term bladder damage, such as fibrosis. For massive, uncontrollable hemorrhage, selective arterial embolization of the internal iliac artery may be performed to block the bladder’s blood supply. The final option for life-threatening bleeding is major surgical intervention, such as urinary diversion or, ultimately, cystectomy (complete removal of the bladder).