Radiation Cystitis Treatment & Management

Updated: Jan 24, 2017
  • Author: Nicolas A Muruve, MD, FACS, FRCSC; Chief Editor: Edward David Kim, MD, FACS  more...
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Treatment

Approach Considerations

Indications for treatment depend on the degree of symptoms present and the patient's sense of need to be treated. Grade 1 and 2 symptoms need treatment only if the patient is bothered by them. These can be managed medically. Observation is acceptable. Management of grade 3 and higher clinical presentations depends on the type of symptom. Voiding dysfunction can be managed medically if the patient desires.

Fistula formation usually requires surgical intervention. Contracted bladder and incontinence require evaluation to determine the degree of disability, bladder compromise, and potential need for surgery.

The use of endoscopic injection sclerotherapy has been reported with good results in a limited number of patients with intractable hemorrhagic cystitis. [10] This treatment involves the injection of a sclerosing agent (eg, 1% ethoxysclerol) into the bleeding areas to control the severe hematuria in patients with otherwise intractable bleeding that is not responding to simpler methods. Further studies are necessary to determine the exact role of this novel type of therapy in selected patients with radiation cystitis.

If symptoms become more severe or oral therapy is not satisfactory, the available literature suggests that hyperbaric oxygen (HBO) therapy yields the most consistent results. [11]

Follow-up

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.

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Pharmacologic Therapy

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. [12, 13]

A randomized, double-blind, placebo-controlled pilot study in 41 men receiving external beam radiation therapy for prostate cancer found that ingestion of cranberry capsules may help prevent or reduce the severity of radiation cystitis, particularly in patients those on low-hydration regimens or with baseline urinary symptoms. The capsules were standardized to contain 72 mg proanthocyanidins. Study patients took one capsule a day at breakfast during treatment and for 2 weeks after treatment completion. [14]

Gacci et al reported that instillation of the combination of hyaluronic acid (HA) and chondroitin sulfate (CS) was effective in reducing nocturnal voiding frequency in men with bladder pain following radiation therapy for prostate cancer. Study patients underwent bladder instillation therapy with HA and CS weekly for the first month and, afterwards, on week 6, 8 and 12. [15]

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Hyperbaric Oxygen Therapy

Therapy for radiation cystitis is primarily aimed at relief of symptoms. The exception is HBO therapy, which can potentially reverse the changes caused by radiation. HBO therapy stimulates angiogenesis, which reverses the vascular changes induced by ionizing radiation. [16] The ability of HBO to preserve bladder function and the noninvasive nature of this treatment are features that favor its use. However, if significant fibrosis and ischemia have already occurred, HBO therapy does not reverse the changes and only prevents further injury. [17, 18]

HBO therapy has a reported response rate of 27-92%, and the recurrence rate is 8-63%. [19, 20] In adults, HBO is administered as 100% oxygen at 2-2.5 atm. Each session lasts from 90-120 minutes, and patients receive HBO sessions 5 days weekly for a total of 40-60 sessions. HBO therapy is a pregnancy category A treatment.

Nakada and colleagues reported good long-term outcomes with HBO treatment in 38 patients with radiation cystitis following irradiation of prostate cancer. At 7-year follow-up, objective and subjective improvements in symptoms were seen in 72-83% of patients. No recurrence was seen in 28 patients (74%); these patients had received an 18% lower radiation dose than patients who did experience recurrence. [21]

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Indications for Surgery

Surgery is reserved for the management of severe complications that do not respond to medical management. Indications for surgery include the following:

  • Ongoing gross hematuria that does not respond to bladder irrigations or that requires numerous transfusions

  • Small, contracted bladder with incontinence or severe frequency

  • Specific complications of radiation (eg, fistulas, hydronephrosis, strictures)

Surgical options for small-volume bladder include bladder augmentation, urinary diversion, and cystectomy.

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Treatment of Hemorrhagic Cystitis

Hemorrhagic cystitis is a more serious complication of radiation cystitis. Cystoscopy is useful in the initial management, both diagnostically to rule out other pathology and for clot evacuation if bleeding is heavy. This can resolve symptoms in up to 61% of patients at initial presentation.

If bleeding is severe, bladder irrigation may be started either alone or in conjunction with hyperbaric therapy. Start continuous bladder irrigation alone first. If this is not successful, try bladder instillation. In order of increasing toxicity, these agents include 1% alum, aminocaproic acid (Amicar), and 1-10% formalin. [22, 23, 24, 25, 26, 27, 28] Other options are oral pentosan polysulfate sodium, HBO therapy, and oral estrogens. [29] If symptoms persist, however, cystoscopic intervention is rarely successful. [30]

Surgical options for hemorrhagic cystitis include the following:

  • Cystoscopy and fulguration

  • Percutaneous nephrostomy tube insertions

  • Internal iliac artery embolization

  • Surgical diversion

  • Cystectomy

Cystectomy for hemorrhagic cystitis is associated with high rates of perioperative complications and mortality. It should be used only after more conservative approaches have been attempted. [31]

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