Hemorrhagic Cystitis Workup

Updated: Oct 03, 2022
  • Author: Joseph Basler, MD, PhD; Chief Editor: Edward David Kim, MD, FACS  more...
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Approach Considerations

Documentation of noninfectious hemorrhagic cystitis requires a negative urine culture for bacteria and viruses. If even "insignificant" growth on an adequately collected voided specimen or any growth on a catheterized specimen is present, antibiotics should be initiated. Certain circumstances seem to predispose to urinary tract infections and cause signs and symptoms disproportionate to the amount of pathogen growth, especially in hemorrhagic cystitis due to radiation treatment or chemotherapy. Empiric antibiotics should be switched to culture-directed agents as soon as sensitivities are available.

In all patients, obtain a complete blood count (CBC), basic metabolic profile, and coagulation studies. The hematocrit is rarely below the reference range during an initial occurrence of hemorrhagic cystitis; however, patients with chronic hemorrhagic cystitis may have a lower hematocrit level and prevailing signs of chronic anemia. The white blood cell (WBC) count may be elevated because of a concurrent infection or because of the treatment (eg, chemotherapy) of the underlying malignancy.

Basic metabolic profile (SMA-7) findings are usually normal but may reflect sequelae due to treatment of the primary condition. Liver function test abnormalities related to the primary process may be found but are generally not related to the hemorrhagic cystitis.

Imaging of the upper tracts and bladder is recommended in all cases of hemorrhagic cystitis to assist in ascertaining the etiology and/or confounding variables. At a minimum, perform bladder and renal ultrasonography with a KUB (kidney, ureter, bladder) film to assess for radio-opaque stones (see the diagnosis algorithm below).

In patients with normal  renal function, computed tomography (CT) urography is the most helpful imaging test in most cases. Cystoscopy is indicated in all but straightforward cases of uncomplicated bacterial cystitis. If a bacterial infection is documented, voiding cystourethrography (VCUG) may be performed, if indicated, after the infection has been cleared.

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

Potential difficulties with the acquisition of urine cultures may arise because of the forced hydration and intravesical irrigation used to evacuate clots. Because of this, it is important to have evaluation protocols that put a high priority on obtaining cultures.

Urine studies for viruses, when indicated, include the following:

  • Viral culture

  • Electron microscopy of bladder biopsy specimens

  • Enzyme-linked immunosorbent assay (ELISA)


Urinary Tract Imaging

Renal and bladder ultrasonography along with a KUB film is an excellent initial screening test to evaluate many causes of hematuria. Anatomic and pathologic changes in the urothelium can occur in the upper urinary tract, which may result in hematuria and possible hydronephrosis.

Renal ultrasonography is a reliable and cost-effective initial modality to identify hydronephrosis. Dilatation of the upper urinary tract can be secondary to obstruction at the ureteral level, secondary to bladder wall thickening, or secondary to reflux of urine. Ultrasonography of the bladder may also help to identify blood clots and evaluate their size.

Evaluation of the complete ureter and enhanced anatomic detail is limited with ultrasonography. Evidence of hydronephrosis or a high index of suspicion should prompt further evaluation with CT or MR urography or retrograde pyelography.

In general, the evaluation of any patient with gross hematuria should include an assessment of the upper urinary tract. Imaging studies are as follows, in descending order of helpfulness:

  • CT urography
  • Magnetic resonance (MR) urography
  • Intravenous pyelography
  • CT scanning without contrast (stone protocol, prone scanning)
  • Renal ultrasonography

When only renal ultrasonography or noncontrast CT scanning is performed, retrograde intravenous pyelography may be necessary to further evaluate urothelium of the upper urinary tract. Even if upper urinary tract lesions are identified, a bladder etiology for hematuria should be suspected and then checked with cystoscopy. [93, 94]

If intravesical sclerotherapy (eg, formalin, silver nitrate) is planned after exhaustion of other control measures, cystography is necessary to determine the bladder capacity and to determine the presence of vesicoureteral reflux (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.



Cystoscopy, with or without retrograde pyelography, is indicated in all cases of hemorrhagic cystitis. This may be delayed until the acute bleeding has been treated with successful use of conservative measures; ie, manual irrigation and continuous bladder irrigation. In this case, outpatient flexible cystoscopy is used typically without need for general anesthesia.

However, cystoscopic clot evacuation is often necessary to facilitate complete clot removal. This allows close inspection of the bladder urothelium and assessment of potential neoplasm(s) as the bleeding source. Use of a rigid cystoscope of the largest possible caliber permits improved removal of clots. Endoscopic inspection is essential in planning treatment and in preventing future episodes.

In the pediatric population, cystoscopy should be considered a first-line therapy in the setting of clot retention or failure of initial conservative therapy. Cystoscopy also allows for evaluation of concomitant neoplasm (fairly uncommon in pediatric population). The endoscopic procedure is performed under general anesthesia in the pediatric population. Complete removal of clot is paramount prior to beginning intravesical irrigation due to the risk of overdistention and potential for bladder rupture in children. Most of the time, cystoscopic findings are nonspecific. The bladder may appear edematous with multiple punctate hemorrhages. Visible areas of active bleeding can be identified and judiciously fulgurated to control bleeding. [95]



Although a staging system for hemorrhagic cystitis has been devised, it 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. The stages are as follows:

  • 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