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Radiation Cystitis Medication

  • Author: Nicolas A Muruve, MD, FACS, FRCSC; Chief Editor: Edward David Kim, MD, FACS  more...
 
Updated: Nov 09, 2014
 

Medication Summary

Pharmacologic therapy for radiation cystitis is primarily aimed at relief of symptoms. Symptomatic frequency and urgency are best treated with anticholinergic agents. Once all other causes of dysuria have been ruled out, phenazopyridine can be used to provide symptomatic relief. If the symptoms of radiation cystitis are not severe but are significant enough for a patient to seek help, pentosan polysulfate sodium (Elmiron), with or without pentoxifylline for pain, is a reasonable first step. For severe hematuria, instillation of a variety of agents into the bladder may be tried.

Formalin, a 37% solution of formaldehyde and water compounded at the pharmacy, is a tissue fixative. Adult dosing depends on the method of administration. Dosing for local therapy consists of 5% formalin pledgets placed endoscopically on bleeding points for 15 minutes and then removed. For bladder irrigation, a 1-10% solution (4% preferred) is used; manually fill the bladder to capacity under gravity (catheter < 15cm above the symphysis pubis); contact time ranges from 14 minutes for a 10% solution to 23 minutes for a 5% solution. This is a painful procedure and requires a general anesthetic. The response rate is 52-89%, and the recurrence rate is 20-25%.

Alum, which is also compounded at the pharmacy, causes protein precipitation in the interstitial spaces and cell membranes, causing contraction of the extracellular matrix and tamponade of bleeding vessels. Exposed capillary epithelium is also sclerosed. In adults, a 1% solution is prepared by mixing 50g of potassium aluminum sulfate in 5L of distilled water; it is run intravesically at a rate of 3-5mL/min and increased to a maximum of 10mL/min if returns are not clear; it is continued for 6 hours after bleeding stops. Alum has a response rate of 50-80%, and the recurrence rate is 10%.

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Analgesics, Urinary

Class Summary

Urinary analgesics provide relief of bladder pain due to interstitial cystitis.

Phenazopyridine (Pyridium, ReAzo, Baridium)

 

Phenazopyridine is an azo dye that has local anesthetic or analgesic action. It acts directly on urinary tract mucosa when excreted.

Pentosan polysulfate sodium (Elmiron)

 

Pentosan polysulfate sodium protects transitional epithelium by restoring the bladder glycosaminoglycan layer. Adult dosing is 100mg orally 3 times daily until symptoms resolve, for a minimum of 4 weeks. The response rate in radiation cystitis is 71-100%, and the recurrence rate is 23%.[29] Sodium pentosan polysulfate is a pregnancy category B drug.

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Hemostatics

Class Summary

Hemostatic agents are potent inhibitors of fibrinolysis and can reverse states that are associated with excessive fibrinolysis.

Aminocaproic acid (Amicar)

 

Aminocaproic acid is an antifibrinolytic agent that inhibits plasminogen activation, thus decreasing plasmin. Adult dosing is 200mg of aminocaproic acid in 1L of isotonic sodium chloride solution. It is run intravesically according to the severity of bleeding and continued for 24 hours after bleeding stops.

Aminocaproic acid has a response rate of 91%, and recurrences have not been reported. This agent is a pregnancy category C drug.

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Estrogen Derivatives

Class Summary

Estrogen derivatives have been used to correct prolonged bleeding time.

Conjugated estrogens (Premarin)

 

The mechanism of action of conjugated estrogens in radiation cystitis is unknown. In patients with renal failure, estrogen has been reported to correct prolonged bleeding time. However, in radiation cystitis complications, bleeding time is usually normal. Adult dosing is 5mg/day orally for 4-7 days.

Conjugated estrogens have a response rate of 100%, and the recurrence rate is 20% (1 report of 5 patients only). Conjugated estrogen is a pregnancy category X drug.

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Hemorheologic Agents

Class Summary

Hemorheologic agents enhance blood flow by reducing components responsible for blood viscosity.

Pentoxifylline (Trental)

 

Pentoxifylline has been shown to relieve pain due to radiation fibrosis. Pentoxifylline and its metabolites improve the flow properties of blood by decreasing its viscosity. This increases blood flow to the affected microcirculation and enhances tissue oxygenation. The precise mode of action of pentoxifylline and the sequence of events leading to clinical improvement remain undefined. Adult dosing is 400mg orally 3 times daily for 6 weeks. Pentoxifylline is a pregnancy category C drug.

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Contributor Information and Disclosures
Author

Nicolas A Muruve, MD, FACS, FRCSC Associate Staff, Department of Urology, Cleveland Clinic Florida

Nicolas A Muruve, MD, FACS, FRCSC is a member of the following medical societies: American College of Surgeons, Society of Urologic Oncology, Canadian Urological Association, American Society of Transplant Surgeons, American Urological Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

Acknowledgements

Michael Grasso III, MD Director of Endourology, Lenox Hill Hospital; Professor and Vice Chairman, Department of Urology, New York Medical College

Michael Grasso III, MD is a member of the following medical societies: American Medical Association, American Urological Association, Endourological Society, Medical Society of the State of New York, National Kidney Foundation, Société Internationale d'Urologie (International Society of Urology), and Society of Laparoendoscopic Surgeons

Disclosure: Karl Storz Endoscopy Consulting fee Consulting; Boston Scientific Consulting fee Consulting; Cook Urologic Consulting fee Consulting

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Dan Theodorescu, MD, PhD Paul A Bunn Professor of Cancer Research, Professor of Surgery and Pharmacology, Director, University of Colorado Comprehensive Cancer Center

Dan Theodorescu, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Urological Association, Medical Society of Virginia, Society for Basic Urologic Research, and Society of Urologic Oncology

Disclosure: Key Genomics Ownership interest Co-Founder-50% Stock Ownership

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Cystoscopic view of a bladder showing the neovascularity and telangiectasia of radiation cystitis.
Cystoscopic view of a bladder showing the neovascularity and telangiectasia of radiation cystitis.
Cystoscopic view of a radiated bladder showing areas of neovascularization next to an area of pallor; the pallor was caused by increased collagen deposition. In such cases, the collagen prevents new vessels from forming in injured areas and contributes to ischemia.
 
 
 
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