Radiation Cystitis Workup
- Author: Nicolas A Muruve, MD, FACS, FRCSC; Chief Editor: Edward David Kim, MD, FACS more...
Radiation cystitis can mimic many different diseases. Neoplasia, urinary tract infection, and stone disease display similar findings. Consequently, a complete evaluation of the urinary tract is required. The initial evaluation should include the following:
Urinalysis to assess for hematuria and pyuria and to measure urine pH
Urine culture to confirm or rule out infection
Urinary cytology to screen for tumor
If the patient has hematuria, a complete blood count (CBC) is required to assess hemoglobin, hematocrit, and adequate platelet count. Gross hematuria is an indication to evaluate volume status, coagulation status, and the need for red blood cell (RBC) transfusion. Cystoscopy and renal imaging are also indicated to rule out other possible causes of genitourinary (GU) bleeding. Prothrombin time (PT) and activated partial thromboplastin time (aPTT) are needed to rule out coagulopathies if the patient is bleeding.
A white blood cell (WBC) count is necessary to assess for infection if the patient is febrile. Electrolytes, blood urea nitrogen (BUN), and creatinine levels are needed to assess renal function; obstructive uropathy may result from stricturing of the urinary tract and poor emptying. Urodynamics may be required if a patient presents with more complicated symptoms, but most symptoms can be evaluated by a thorough history and physical examination.
Avoid bladder biopsy because it may cause persistent bleeding or even fistula formation. However, judicious use of bladder biopsies may be indicated if a suspicious lesion or recurrent tumor is suggested.
Follow-up care for radiation cystitis is generally supportive. Symptoms can be recurrent or even persistent, as in the case of dysfunctional voiding. Because symptomatic manifestations of radiation cystitis can occur many years after primary radiation therapy, regular clinical follow-up care and good communication with patients are essential.
Urodynamic studies are needed only when the diagnosis remains unclear after the history and physical examination. Urodynamics can help to assess for decreased bladder volume, postvoid residual urine, and detrusor instability. All are potentially present in radiation cystitis but are not specific for the disease.
Reported findings in acute cases include the following:
Detrusor instability (40-50% of patients)
Decreased peak flow rate
Decreased bladder compliance
Decreased bladder volume (approximately 20% volume reduction)
After the acute phase has passed (6mo), most bladder parameters return to normal. Some authors report a persistent loss of bladder compliance; however, it is not significantly different from that in control subjects.
Cystoscopy is used to confirm the diagnosis and to rule out other conditions, such as bladder cancer or other recurrent metastatic tumors. Cystoscopy can be combined with retrograde pyelography, if needed.
On cystoscopy (see the images below), acute radiation injury is characterized by changes such as the following:
Prominent submucosal vascularity
Cystoscopic findings in chronic radiation injury can be similar to those in acute injury, with areas of extreme pallor between erythematous areas and petechiae (see the image below).
Imaging studies may consist of intravenous pyelography (IVP), CT urography, or renal ultrasonography. IVP is useful to evaluate anatomic abnormalities of the GU tract (eg, stricturing, fistula formation). If hematuria is present, IVP or CT urography is needed to rule out other causes of bleeding, such as calculus disease and neoplasia. As an alternative, ultrasonography can be used to assess for hydronephrosis due to scarring, renal tumors (as another cause of bleeding), and calculus disease.
CT scanning may also help in the diagnosis of bladder fistulas. Findings in patients with fistulas include the following :
Intravesical air (90%)
Passage of orally or rectally administered contrast medium into the bladder (20%)
Focal bladder-wall thickening (90%)
Thickening of adjacent bowel wall (85%)
Extraluminal mass that often contains air (75%)
Cancer Facts & Figures 2014. American Cancer Society. Available at http://www.cancer.org/acs/groups/content/@research/documents/webcontent/acspc-042151.pdf. Accessed: October 30, 2014.
Nonaka T, Nakayama Y, Mizoguchi N, et al. Definitive radiation therapy for invasive carcinoma of the vagina: impact of high-dose rate intracavitary brachytherapy. Int J Clin Oncol. 2012 Feb 7. [Medline].
Pilepich MV, Krall J, George FW, Asbell SO, Plenk HD, Johnson RJ, et al. Treatment-related morbidity in phase III RTOG studies of extended-field irradiation for carcinoma of the prostate. Int J Radiat Oncol Biol Phys. 1984 Oct. 10(10):1861-7. [Medline].
Perez CA, Grigsby PW, Lockett MA, Chao KS, Williamson J. Radiation therapy morbidity in carcinoma of the uterine cervix: dosimetric and clinical correlation. Int J Radiat Oncol Biol Phys. 1999 Jul 1. 44(4):855-66. [Medline].
Lips IM, Dehnad H, van Gils CH, Boeken Kruger AE, van der Heide UA, van Vulpen M. High-dose intensity-modulated radiotherapy for prostate cancer using daily fiducial marker-based position verification: acute and late toxicity in 331 patients. Radiat Oncol. 2008 May 21. 3:15. [Medline]. [Full Text].
Kim SY, Hong YS, Kim DY, et al. Preoperative chemoradiation with cetuximab, irinotecan, and capecitabine in patients with locally advanced resectable rectal cancer: a multicenter phase II study. Int J Radiat Oncol Biol Phys. 2011 Nov 1. 81(3):677-83. [Medline].
Goldman SM, Fishman EK, Gatewood OM, Jones B, Siegelman SS. CT in the diagnosis of enterovesical fistulae. AJR Am J Roentgenol. 1985 Jun. 144(6):1229-33. [Medline].
Tunuguntla HS, Bhandari M, Srivastava A, Kapoor R, Saha TK. Endoscopic injection sclerotherapy control of intractable hematuria following radiation-induced hemorrhagic cystitis. A novel approach. Arch Esp Urol. 2000 May. 53(4):396-402. [Medline].
Parsons CL. Successful management of radiation cystitis with sodium pentosanpolysulfate. J Urol. 1986 Oct. 136(4):813-4. [Medline].
Sandhu SS, Goldstraw M, Woodhouse CR. The management of haemorrhagic cystitis with sodium pentosan polysulphate. BJU Int. 2004 Oct. 94(6):845-7. [Medline].
Weiss JP, Mattei DM, Neville EC, Hanno PM. Primary treatment of radiation-induced hemorrhagic cystitis with hyperbaric oxygen: 10-year experience. J Urol. 1994 Jun. 151(6):1514-7. [Medline].
Sanchiz F, Millá A, Artola N, Julià JC, Moya LM, Pedro A, et al. Prevention of radioinduced cystitis by orgotein: a randomized study. Anticancer Res. 1996 Jul-Aug. 16(4A):2025-8. [Medline].
Osaki T, Ueta E, Yoneda K, Hirota J, Yamamoto T. Prophylaxis of oral mucositis associated with chemoradiotherapy for oral carcinoma by Azelastine hydrochloride (Azelastine) with other antioxidants. Head Neck. 1994 Jul-Aug. 16(4):331-9. [Medline].
Neheman A, Nativ O, Moskovitz B, Melamed Y, Stein A. Hyperbaric oxygen therapy for radiation-induced haemorrhagic cystitis. BJU Int. 2005 Jul. 96(1):107-9. [Medline].
Allen S, Kilian C, Phelps J, et al. The use of hyperbaric oxygen for treating delayed radiation injuries in gynecologic malignancies: a review of literature and report of radiation injury incidence. Support Care Cancer. 2012 Jan 14. [Medline].
Hampson NB, Holm JR, Wreford-Brown CE, et al. Prospective assessment of outcomes in 411 patients treated with hyperbaric oxygen for chronic radiation tissue injury. Cancer. 2011 Dec 2. [Medline].
Del Pizzo JJ, Chew BH, Jacobs SC, Sklar GN. Treatment of radiation induced hemorrhagic cystitis with hyperbaric oxygen: long-term followup. J Urol. 1998 Sep. 160(3 Pt 1):731-3. [Medline].
Nakada T, Nakada H, Yoshida Y, Nakashima Y, Banya Y, Fujihira T, et al. Hyperbaric oxygen therapy for radiation cystitis in patients with prostate cancer: a long-term follow-up study. Urol Int. 2012. 89(2):208-14. [Medline].
Dewan AK, Mohan GM, Ravi R. Intravesical formalin for hemorrhagic cystitis following irradiation of cancer of the cervix. Int J Gynaecol Obstet. 1993 Aug. 42(2):131-5. [Medline].
Donahue LA, Frank IN. Intravesical formalin for hemorrhagic cystitis: analysis of therapy. J Urol. 1989 Apr. 141(4):809-12. [Medline].
Goswami AK, Mahajan RK, Nath R, Sharma SK. How safe is 1% alum irrigation in controlling intractable vesical hemorrhage?. J Urol. 1993 Feb. 149(2):264-7. [Medline].
Likourinas M, Cranides A, Jiannopoulos B, Kostakopoulos A, Dimopoulos C. Intravesical formalin for the control of intractable bladder haemorrhage secondary to radiation cystitis or bladder cancer. Urol Res. 1979 Jun 22. 7(2):125-6. [Medline].
Lowe BA, Stamey TA. Endoscopic topical placement of formalin soaked pledgets to control localized hemorrhage due to radiation cystitis. J Urol. 1997 Aug. 158(2):528-9. [Medline].
Nurmi M, Puntala P, Torniainen K. Alum irrigation in the treatment of severe haemorrhage from the bladder. Ann Chir Gynaecol. 1987. 76(3):173-5. [Medline].
Singh I, Laungani GB. Intravesical epsilon aminocaproic acid in management of intractable bladder hemorrhage. Urology. 1992 Sep. 40(3):227-9. [Medline].
Liu YK, Harty JI, Steinbock GS, Holt HA Jr, Goldstein DH, Amin M. Treatment of radiation or cyclophosphamide induced hemorrhagic cystitis using conjugated estrogen. J Urol. 1990 Jul. 144(1):41-3. [Medline].
Kaplan JR, Wolf JS Jr. Efficacy and survival associated with cystoscopy and clot evacuation for radiation or cyclophosphamide induced hemorrhagic cystitis. J Urol. 2009 Feb. 181(2):641-6. [Medline].
Linder BJ, Tarrell RF, Boorjian SA. Cystectomy for Refractory Hemorrhagic Cystitis: Contemporary Etiology, Presentation and Outcomes. J Urol. 2014 Jun 14. [Medline].
Hampson SJ, Woodhouse CR. Sodium pentosanpolysulphate in the management of haemorrhagic cystitis: experience with 14 patients. Eur Urol. 1994. 25(1):40-2. [Medline].