eMedicine Specialties > Pediatrics: Surgery > Urology

Hemorrhagic Cystitis: Follow-up

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

Follow-up

Further Inpatient Care

  • The patient should remain well hydrated after the resolution of the hematuria.
  • If a urethral catheter is still in place, pay careful attention to clot formation and urinary tract infections.

Further Outpatient Care

  • Close follow-up is warranted.
  • Previous injury to the bladder by radiation and chemotherapy agents and possible damage to urothelium and bladder muscle by therapeutic agents, such as formalin, require routine evaluation of upper tracts and bladder with renal bladder ultrasonography and additional studies, as needed. Life-long follow-up may be required.
  • The oncology service must be aware of the patient's history of hemorrhagic cystitis (HC) and maximize preventive measures before given any additional oncologic therapy.

Transfer

  • The oncologic patient with hemorrhagic cystitis should be treated at an institution familiar with this condition.
  • The patient with severe hemorrhagic cystitis should be transferred only after his or her condition is stabilized.
  • Only a few facilities offer hyperbaric oxygen therapy. Patients requiring this therapy should be transferred early to these facilities.

Deterrence/Prevention

  • Preventive approaches are available to decrease the urotoxicity related to cyclophosphamide therapy, unlike the other causes of hemorrhagic cystitis.
    • The goal of this strategy is aimed at neutralization or detoxification of acrolein.
    • Most oncology centers recommend vigorous hydration combined with frequent voiding or use of an indwelling bladder catheter to reduce acrolein contact time with the bladder.
  • Two medications, N -acetylcysteine (Mucomyst) and 2-mercaptoethane sulfonate (ie, mesna [Mesnex]), bind to acrolein and form a nonurotoxic compound.
    • Unlike acetylcysteine, mesna specifically binds to acrolein and does not interfere with its therapeutics effects when administered systemically.
    • Routine prophylactic administration of mesna is recommended in patients receiving cyclophosphamide therapy.
  • Discontinuation of cyclophosphamide is mandatory in patients with developing hemorrhagic cystitis because hematuria can subside with this maneuver in most patients.
  • Unlike cyclophosphamide hemorrhagic cystitis, no effective preventive measures are available for radiation-induced hemorrhagic cystitis.

Complications

  • Hemorrhagic cystitis is considered a complication of previous oncologic treatments.
  • Additional complications are related to the agents used to control the bleeding.
  • The specific complications are discussed above.

Prognosis

  • The prognosis in patients with hemorrhagic cystitis is related to successful treatment of their primary oncologic condition.
  • Most patients are successfully treated, with a resolution of hemorrhagic cystitis. However, long-term effects on the bladder may include increased bladder fibrosis, reduced bladder capacity, and upper tract deterioration.
  • Patient with severe hemorrhagic cystitis refractory to medical intervention are at an increased risk for mortality.

Patient Education

  • The physicians treating oncology patients must be aware of the possible preventive measures against hemorrhagic cystitis.
  • Patients at high risk must be educated about the possibility of the development of hemorrhagic cystitis and the need for early intervention.
  • For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also see eMedicine's patient education article Blood in the Urine.

Miscellaneous

Medicolegal Pitfalls

  • Potential medicolegal problems are present in patients with hemorrhagic cystitis (HC) who are in a fragile condition.
  • Hemorrhagic cystitis is a complication of previous therapy with potential morbidity and mortality.
  • The possibility of developing hemorrhagic cystitis must be addressed with every patient undergoing oncologic treatment.
  • After a patient develops hemorrhagic cystitis, detailed discussion of the treatments, complications, and possible mortality risk should be presented to the patient and/or parents.

Special Concerns

  • Prevention is essential in this condition.
    • Two standard methods of prevention are hyperhydration and mesna administration.
    • Controversial methods include prophylactic bladder irrigation and hourly voiding.
  • Hemorrhagic cystitis is source of great morbidity and mortality.
    • Prevention is the most important factor.
    • Diagnosis and treatment should be prompt.
    • In a few patients, an aggressive approach is warranted to save their lives.
 


More on Hemorrhagic Cystitis

Overview: Hemorrhagic Cystitis
Differential Diagnoses & Workup: Hemorrhagic Cystitis
Treatment & Medication: Hemorrhagic Cystitis
Follow-up: Hemorrhagic Cystitis
Multimedia: Hemorrhagic Cystitis
References
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References

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Further Reading

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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

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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.

 
 
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