Chemical‐ and radiation‐induced haemorrhagic cystitis: current treatments and challenges

Abstract

To review the published data on predisposing risk factors for cancer treatment-induced haemorrhagic cystitis (HC) and the evidence for the different preventive and therapeutic measures that have been used in order to help clinicians optimally define and manage this potentially serious condition.Despite recognition that HC can be a significant complication of cancer treatment, there is currently a lack of UK-led guidelines available on how it should optimally be defined and managed.A systematic literature review was undertaken to evaluate the evidence for preventative measures and treatment options in the management of cancer treatment-induced HC.There is a wide range of reported incidence due to several factors including variability in study design and quality, the type of causal agent, the grading of bleeding, and discrepancies in definition criteria.The most frequently reported causal factors are radiotherapy to the pelvic area, where HC has been reported in up to 20% of patients, and treatment with cyclophosphamide and bacillus Calmette-Guérin, where the incidence has been reported as up to 30%.Mesna (2-mercaptoethane sodium sulphonate), hyperhydration and bladder irrigation have been the most frequently used prophylactic measures to prevent treatment-related cystitis, but are not always effective.Cranberry juice is widely cited as a preventative measure and sodium pentosanpolysulphate as a treatment, although the evidence for both is very limited.The best evidence exists for intravesical hyaluronic acid as an effective preventative and active treatment, and for hyperbaric oxygen as an equally effective treatment option.The lack of robust data and variability in treatment strategies used highlights the need for further research, as well as best practice guidance and consensus on the management of HC.

Intravesical formalin for hemorrhagic cystitis: A contemporary cohort

“…1 One such entity is hemorrhagic cystitis, which is characterized by diffuse bleeding throughout the urothelium and is typically secondary to radiation or chemotherapy exposure. [2][3][4][5] Notably, the presentation of hemorrhagic cystitis may vary from mild, self-limited gross hematuria to refractory, life-threatening hemorrhage with clot retention requiring blood transfusion and emergent surgical or radiological intervention. 6 Unfortunately, despite the clinical challenge that severe hemorrhagic cystitis can present, data regarding treatment options is sparse.…”

“…Notably, while commonly used, there is little supporting literature to define outcomes with intravesical therapies, such as alum, silver nitrate, and formalin. 2,5 Intravesical formalin instillation, first reported in 1969, was initially used in the management of refractory bladder hemorrhage from inoperable cancer. 8 The proposed mechanism of action involves capillary occlusion and protein fixation at the level of the urothelium.…”

Intravesical silver nitrate for refractory hemorrhagic cystitis

“…[1] Hemorrhagic cystitis is a challenging clinical entity due to the diffuse nature of bleeding from the urothelium, and is most commonly secondary to pelvic radiation therapy. [2,3] Over time, radiation therapy can cause obliterative endarteritis which in turn results in bladder mucosa ischemia, tissue breakdown, and hemorrhage. [4,5] The degree of hematuria in patients with hemorrhagic cystitis can be highly variable, but in its most severe form, the hematuria can require blood transfusions, be refractory to intravesical therapies and may require urinary diversion.…”

Integrative review on the non‐invasive management of lower urinary tract symptoms in men following treatments for pelvic malignancies

“…Many of these men continue to experience symptoms that impact on quality of life such as urinary and bowel problems, haematuria, rectal bleeding, pain and sexual dysfunction 2. Common symptoms as a result of cancer therapy have been addressed in substantive reviews 3, 4, 5, 6. Urinary symptoms despite the high prevalence in men after cancer treatment and the links to negative effect on quality of life 7 have not yet been addressed.…”

“…LUTS occurs in an estimated 71% of patients receiving maintenance BCG for bladder cancer 4. Intravesical mitomycin C (MMC) has also been known to exacerbate LUTS in these patients 43, 44, 45.…”