Hemorrhagic cystitis is a medical condition characterized by inflammation of the bladder lining and bleeding into the urine. Bleeding can range from microscopic to visible blood or clots. The condition often presents with lower urinary tract symptoms, including discomfort during urination, frequent urges to urinate, and sometimes difficulty emptying the bladder.
Causes of Hemorrhagic Cystitis
Chemotherapy drugs, particularly cyclophosphamide and ifosfamide, are common causes. These medications produce a toxic metabolite called acrolein, which irritates and damages the bladder lining as it is excreted. Incidence can range from 0.6% to 15% with cyclophosphamide and up to 30% with ifosfamide.
Radiation therapy directed at the pelvic area, often used for cancer treatment, can also cause hemorrhagic cystitis. This damages the bladder’s small blood vessels, leading to a lack of oxygen, tissue damage, and bleeding. Onset can be immediate or delayed by months to years after treatment.
Viral infections are another cause, particularly in individuals with compromised immune systems, such as those undergoing chemotherapy or organ transplantation. Adenovirus, especially serotypes 11 and 21, is a frequent cause in children. BK virus is commonly associated with the condition in bone marrow transplant recipients, affecting 5.7% to 7.7% of these patients. Bacterial infections can also lead to hemorrhagic cystitis, though these respond well to standard treatments. Less common causes include exposure to certain industrial chemicals like aniline and toluidine, or rarely, other medications such as penicillins.
Medical and Supportive Treatments
Initial management involves supportive care to reduce symptoms and address the underlying cause. Aggressive hydration, either orally or intravenously, helps dilute the urine, flush the bladder, and reduce irritant concentration. This also aids in removing blood clots. Fluids may be administered at approximately twice the maintenance rate for 24 to 48 hours after the causative agent is removed.
Pain management is also important. Over-the-counter pain relievers can help with mild discomfort, while prescription pain medications and antispasmodics may be necessary for more severe bladder pain and spasms. These medications alleviate involuntary bladder muscle contractions.
Continuous bladder irrigation with normal saline is frequently employed to remove blood clots and reduce bleeding. This involves continuously flushing the bladder through a catheter, clearing accumulated clots and preventing further obstruction. While effective for clot removal, it does not directly treat underlying bladder wall damage.
Specific medications are used depending on the cause. For chemotherapy-induced cases, mesna (2-mercaptoethane sulfonate sodium) is often administered. Mesna binds to and neutralizes acrolein, the toxic metabolite responsible for bladder damage. Antiviral medications may be prescribed if a viral infection, such as BK virus, is identified as the cause, especially in immunocompromised patients. For significant blood loss leading to anemia, blood transfusions may be necessary to restore red blood cell levels.
Advanced and Invasive Interventions
When less invasive methods do not control bleeding, more advanced interventions are considered. Intravesical therapy involves instilling medications directly into the bladder. Alum (aluminum potassium sulfate) is a common agent that helps stop bleeding by causing proteins to precipitate and blood vessels to constrict. Prostaglandins, such as carboprost tromethamine, can also be instilled, promoting vascular smooth muscle constriction and platelet aggregation to reduce bleeding.
Formalin, a highly caustic agent, is reserved as a last-resort intravesical treatment for severe, intractable bleeding due to its potential for significant side effects. Hyperbaric oxygen therapy, which involves breathing pure oxygen in a pressurized chamber, can also be used. This therapy increases oxygen delivery to damaged bladder tissues, promoting healing and reducing bleeding, and has shown success in refractory cases.
For persistent and severe bleeding, embolization is an option where interventional radiologists block specific blood vessels supplying the bladder. This reduces blood flow to the bleeding areas, effectively stopping the hemorrhage. Cystoscopy with fulguration involves inserting a thin, lighted tube into the bladder to visualize bleeding sites and then cauterize them directly using an electrical current. In the most severe, life-threatening cases that do not respond to other treatments, surgical options like urinary diversion or cystectomy (removal of the bladder) may be considered as definitive, highly invasive last resorts.
Preventing Recurrence
Preventing recurrence is a significant focus, particularly for individuals undergoing treatments known to cause the condition. For patients receiving cyclophosphamide or ifosfamide chemotherapy, prophylactic mesna administration is a primary preventive measure. Mesna is given intravenously concurrently with chemotherapy, or orally afterward, to neutralize bladder-damaging metabolites.
Maintaining aggressive hydration is also a cornerstone of prevention. High fluid intake dilutes toxic substances in the urine and promotes their rapid excretion, reducing contact time with the bladder lining. Monitoring for early symptoms and prompt medical attention are also important. Regular urinalysis can detect microscopic blood early, allowing for timely intervention before the condition becomes severe. While lifestyle adjustments are less impactful for chemotherapy or radiation-induced cases, avoiding known bladder irritants can support bladder health.