eMedicine Specialties > Pediatrics: Surgery > Urology

Hemorrhagic Cystitis: Differential Diagnoses & Workup

Author: Marcos Perez-Brayfield, MD, Consulting Staff, HIMA-San Pablo, San Juan, Puerto Rico
Coauthor(s): Andrew J Kirsch, MD, FAAP, FACS, Clinical Professor of Urology, Emory University School of Medicine, Children's Healthcare of Atlanta; President, Georgia Urology, PA
Contributor Information and Disclosures

Updated: Sep 18, 2009

Differential Diagnoses

Other Problems to Be Considered

Other causes of gross hematuria should be considered, such as bacterial infection of the bladder, bladder urolithiasis, bleeding caused by a vascular lesion (hemangioma or arteriovenous malformation), urothelial tumor, or interstitial cystitis.

Workup

Laboratory Studies

  • The evaluation of the pediatric oncology patient with hemorrhagic cystitis (HC) includes microbiology, imaging studies, and possibly cystoscopy.
  • In all patients, obtain a CBC count with platelet counts, coagulation studies, and urine cultures for bacteria and virus, and, at a minimum, perform bladder and renal ultrasonography.
    • If a bacterial infection is documented, voiding cystourethrography (VCUG) should be performed.
    • Oncology patients with pancytopenia can present with bleeding diathesis, including hematuria.
    • Transfusion with platelets or coagulation products aids in the successful treatment of hemorrhagic cystitis.
    • In addition, patients with pancytopenia are immunocompromised and are at high risk for infections, including bacterial and viral cystitis, and, thus, urine culture for these pathogens should be obtained.
    • Results from both the bacterial and viral cultures guide the selection of antibiotic and antiviral therapy.
    • Potential difficulties with the acquisition of urine cultures arises because of the forced hydration and intravesical irrigation used to evacuate clots.
  • Urine studies for viruses include the following:
    • Viral culture
    • Electron microscopy of bladder biopsy specimens
    • Enzyme-linked immunosorbent assay (ELISA)

Imaging Studies

  • Renal bladder ultrasonography is an excellent screening test to rule out many causes of hematuria.
    • Because changes in the urothelium can occur in the urinary upper tract, renal ultrasonography is mandatory to identify hydronephrosis.
    • Dilatation of the upper tract can be secondary to obstruction at the ureteral level or secondary to bladder-wall thickening.
    • Ultrasonography of the bladder also helps to identify blood clots and evaluate their size.
  • In addition, if intravesical sclerotherapy is required, cystography is necessary to determine the bladder capacity and to determine the presence of VUR. The administration of sclerotherapy in the presence of VUR can lead to ureteral fibrosis, obstruction, and possible renal failure, as well as systemic absorption of the agent.
  • CT scanning or MRI is not routinely used in patients with hemorrhagic cystitis.
Diagnosis algorithm. R/O = rule out; US = ultraso...

Diagnosis algorithm. R/O = rule out; US = ultrasonography; VUR = vesicoureteral reflux.

[ CLOSE WINDOW ]
Diagnosis algorithm. R/O = rule out; US = ultraso...

Diagnosis algorithm. R/O = rule out; US = ultrasonography; VUR = vesicoureteral reflux.


Procedures

  • Cystoscopy
    • Cystoscopy should be considered if the patient has clot retention. Otherwise, cystoscopy contributes little beyond what ultrasonography and VCUG reveal.
    • The endoscopic procedure is performed under general anesthesia in the pediatric population.
    • Attempts to use the largest caliber scope facilitate removal of clots if needed.
    • Most of the time, cystoscopic findings are nonspecific. The bladder appears edematous with multiple punctate hemorrhages. These findings can be isolated to an area of the bladder or diffuse. Areas of active bleeding can be identified.

Histologic Findings

Nonspecific findings include hemorrhage, intense inflammatory infiltrates, chronic inflammation, and fibrosis.

Staging

The staging system for hemorrhagic cystitis has little clinical significance and does not really help in the management of this condition. The main use for the staging system is the standardization of scientific studies on this subject.

  • 0 - No symptoms of bladder irritability or hemorrhage
  • 1 - Microscopic hematuria/frequency/dysuria
  • 2 - Macroscopic hematuria
  • 3 - Macroscopic hematuria with small clots
  • 4 - Massive macroscopic hematuria requiring instrumentation for clot evacuation and/or causing urinary obstruction
Grading of hemorrhagic cystitis.

Grading of hemorrhagic cystitis.

[ CLOSE WINDOW ]
Grading of hemorrhagic cystitis.

Grading of hemorrhagic cystitis.


More on Hemorrhagic Cystitis

Overview: Hemorrhagic Cystitis
Differential Diagnoses & Workup: Hemorrhagic Cystitis
Treatment & Medication: Hemorrhagic Cystitis
Follow-up: Hemorrhagic Cystitis
Multimedia: Hemorrhagic Cystitis
References
[ CLOSE WINDOW ]

References

  1. Corman JM, McClure D, Pritchett R, et al. Treatment of radiation induced hemorrhagic cystitis with hyperbaric oxygen. J Urol. Jun 2003;169(6):2200-2. [Medline].

  2. Del Pizzo JJ, Chew BH, Jacobs SC, Sklar GN. Treatment of radiation induced hemorrhagic cystitis with hyperbaric oxygen: long-term followup. J Urol. Sep 1998;160(3 Pt 1):731-3. [Medline].

  3. Cohen MH, Dagher R, Griebel DJ, et al. U.S. Food and Drug Administration drug approval summaries: imatinib mesylate, mesna tablets, and zoledronic acid. Oncologist. 2002;7(5):393-400. [Medline]. [Full Text].

  4. deVries CR, Freiha FS. Hemorrhagic cystitis: a review. J Urol. Jan 1990;143(1):1-9. [Medline].

  5. Dewan AK, Mohan GM, Ravi R. Intravesical formalin for hemorrhagic cystitis following irradiation of cancer of the cervix. Int J Gynaecol Obstet. Aug 1993;42(2):131-5. [Medline].

  6. Donahue LA, Frank IN. Intravesical formalin for hemorrhagic cystitis: analysis of therapy. J Urol. Apr 1989;141(4):809-12. [Medline].

  7. Ehrlich RM, Freedman A, Goldsobel AB, Stiehm ER. The use of sodium 2-mercaptoethane sulfonate to prevent cyclophosphamide cystitis. J Urol. May 1984;131(5):960-2. [Medline].

  8. Haselberger MB, Schwinghammer TL. Efficacy of mesna for prevention of hemorrhagic cystitis after high-dose cyclophosphamide therapy. Ann Pharmacother. Sep 1995;29(9):918-21. [Medline].

  9. Iavazzo C, Athanasiou S, Pitsouni E, Falagas ME. Hyaluronic acid: an effective alternative treatment of interstitial cystitis, recurrent urinary tract infections, and hemorrhagic cystitis?. Eur Urol. Jun 2007;51(6):1534-40; discussion 1540-1. [Medline].

  10. Kanwar VS, Jenkins JJ, Mandrell BN, Furman WL. Aluminum toxicity following intravesical alum irrigation for hemorrhagic cystitis. Med Pediatr Oncol. Jul 1996;27(1):64-7. [Medline].

  11. Lee HJ, Pyo JW, Choi EH, et al. Isolation of adenovirus type 7 from the urine of children with acute hemorrhagic cystitis. Pediatr Infect Dis J. Jul 1996;15(7):633-4. [Medline].

  12. Levine LA, Richie JP. Urological complications of cyclophosphamide. J Urol. May 1989;141(5):1063-9. [Medline].

  13. Liu YK, Harty JI, Steinbock GS, et al. Treatment of radiation or cyclophosphamide induced hemorrhagic cystitis using conjugated estrogen. J Urol. Jul 1990;144(1):41-3. [Medline].

  14. McCarville MB, Hoffer FA, Gingrich JR, Jenkins JJ 3rd. Imaging findings of hemorrhagic cystitis in pediatric oncology patients. Pediatr Radiol. Mar 2000;30(3):131-8. [Medline].

  15. Miller LJ, Chandler SW, Ippoliti CM. Treatment of cyclophosphamide-induced hemorrhagic cystitis with prostaglandins. Ann Pharmacother. May 1994;28(5):590-4. [Medline].

  16. Raboni SM, Siqueira MM, Portes SR, Pasquini R. Comparison of PCR, enzyme immunoassay and conventional culture for adenovirus detection in bone marrow transplant patients with hemorrhagic cystitis. J Clin Virol. Aug 2003;27(3):270-5. [Medline].

  17. Rodriguez Luna JM, Teruel JL, Vallejo J, et al. Control of massive hematuria in idiopathic hemorrhagic cystitis after administration of conjugated estrogen. J Urol. Nov 1992;148(5):1524-5. [Medline].

  18. Russo P. Urologic emergencies in the cancer patient. Semin Oncol. Jun 2000;27(3):284-98. [Medline].

  19. Seber A, Shu XO, Defor T, et al. Risk factors for severe hemorrhagic cystitis following BMT. Bone Marrow Transplant. Jan 1999;23(1):35-40. [Medline].

  20. Tirindelli MC, Flammia G, Sergi F, Cerretti R, Cudillo L, Picardi A, et al. Fibrin glue for refractory hemorrhagic cystitis after unrelated marrow, cord blood, and haploidentical hematopoietic stem cell transplantation. Transfusion. Jan 2009;49(1):170-5. [Medline].

  21. Trigg ME, O'Reilly J, Rumelhart S, et al. Prostaglandin E1 bladder instillations to control severe hemorrhagic cystitis. J Urol. Jan 1990;143(1):92-4. [Medline].

  22. Vicente J, Rios G, Caffaratti J. Intravesical formalin for the treatment of massive hemorrhagic cystitis: retrospective review of 25 cases. Eur Urol. 1990;18(3):204-6. [Medline].

  23. West NJ. Prevention and treatment of hemorrhagic cystitis. Pharmacotherapy. Jul-Aug 1997;17(4):696-706. [Medline].

  24. Youn T, Trachtman H, Gauthier B. Clinical spectrum of gross hematuria in pediatric patients. Clin Pediatr (Phila). Mar 2006;45(2):135-41. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

hemorrhagic cystitis, gross hematuria, HC, urinary frequency, urgency, dysuria, cyclophosphamide HC, cyclophosphamide hemorrhagic cystitis, viral-induced HC, viral-induced hemorrhagic cystitis, radiation-induced HC, radiation-induced hemorrhagic cystitis, bone marrow transplantation

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Marcos Perez-Brayfield, MD, Consulting Staff, HIMA-San Pablo, San Juan, Puerto Rico
Marcos Perez-Brayfield, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, and American Urological Association
Disclosure: Nothing to disclose.

Coauthor(s)

Andrew J Kirsch, MD, FAAP, FACS, Clinical Professor of Urology, Emory University School of Medicine, Children's Healthcare of Atlanta; President, Georgia Urology, PA
Andrew J Kirsch, MD, FAAP, FACS is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, and Society for Fetal Urology
Disclosure: QMED Grant/research funds Investigation, Consulting; COOK Urological Royalty Consulting

Medical Editor

Howard M Snyder III, MD, Professor, Department of Surgery, Division of Pediatric Urology, University of Pennsylvania School of Medicine
Howard M Snyder III, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Urological Association, and National Kidney Foundation
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Harry P Koo, MD, Chairman of Urology Division and Director of Pediatric Urology, Virginia Commonwealth University; Professor of Surgery, VCU School of Medicine, Medical College of Virginia; Director of Urology, Children's Hospital of Richmond
Harry P Koo, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, and American Urological Association
Disclosure: Nothing to disclose.

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Marc Cendron, MD, Associate Professor of Surgery, Harvard School of Medicine; Consulting Staff, Department of Urological Surgery, Children's Hospital Boston
Marc Cendron, MD is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, European Society for Paediatric Urology, Johns Hopkins Medical and Surgical Association, New Hampshire Medical Society, Society for Fetal Urology, and Society for Pediatric Urology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.