Hemorrhagic Cystitis: Causes, Symptoms, Treatment, Risk Factors, Diagnosis

What is Hemorrhagic Cystitis?

Hemorrhagic cystitis is a condition in which damage occurs to the inner lining of the bladder as well as the blood vessels that supply blood to the inside of your bladder. Hemorrhagic stands for bleeding while cystitis means inflammation of the bladder. If you have been diagnosed with hemorrhagic cystitis (HC), then this means that you have the signs and symptoms of bladder inflammation along with blood in your urine.

What is Hemorrhagic Cystitis?

There are four grades, or types, of the condition. The stage of the disease depends on the amount of blood that is present in your urine. These include:

Grade I. This type of hemorrhagic cystitis has microscopic bleeding in the urine, it is not visible

Grade II. This type of hemorrhagic cystitis is marked by visible bleeding in the urine

Grade III. There is bleeding along with small clots present in the urine

Grade IV. This is the most severe type of hemorrhagic cystitis and there is bleeding present with clots that are large enough to actually block the urine flow from the bladder and this requires removal

What are the Causes of Hemorrhagic Cystitis?

Two of the most common causes of long-lasting and severe hemorrhagic cystitis are radiation therapy and chemotherapy. Infections are also known to cause hemorrhagic cystitis, though hemorrhagic cystitis caused by an infection is usually less severe and do not last long. This type of hemorrhagic cystitis is also easier to treat.

One of the rare causes of hemorrhagic cystitis is working in an industry where you are regularly exposed to toxins from insecticides or aniline dyes.

Hemorrhagic Cystitis Caused by Chemotherapy. One of the common causes of hemorrhagic cystitis is chemotherapy, including drugs such as ifosfamide or cyclophosphamide. These chemotherapy drugs are known to break down into the toxic compound acrolein. Acrolein travels to the bladder, causing damage that leads to hemorrhagic cystitis – though it might take months or weeks after chemotherapy sessions for the symptoms of hemorrhagic cystitis to develop.(1) It has also been observed that the treatment of bladder cancer with bacillus Calmette-Guerin (BCG) can also lead to hemorrhagic cystitis as the drug BCG is placed into the bladder. However, other cancer drugs such as thiotepa and busulfan, are not typically known to cause hemorrhagic cystitis.

Hemorrhagic Cystitis Caused by Radiation Therapy. When radiation therapy is targeted to the pelvic area, it can cause hemorrhagic cystitis because of the fact that it damages the blood vessels that supply blood to the bladder lining. This causes scarring, ulceration, and bleeding. Hemorrhagic cystitis can occur even years or just months after stopping radiation therapy.

Hemorrhagic Cystitis Caused by Infections. There are also certain commonly occurring infections that can cause hemorrhagic cystitis. These include viruses such as polyoma virus, adenovirus, and the type 2 herpes simplex virus. Fungi, parasites, and bacteria are also some of the lesser known causes of hemorrhagic cystitis. Most of the people who have hemorrhagic cystitis.

Symptoms of Hemorrhagic Cystitis

One of the primary symptoms of hemorrhagic cystitis is the presence of blood of urine. During grade I of the condition, there is microscopic blood present in the urine, so you are unlikely to see it. In the later grades of hemorrhagic cystitis, it is possible that you see blood-tinged urine, blood clots in the urine, or bloody urine. In stage IV of hemorrhagic cystitis, blood clots are likely to fill up your bladder and stop the flow of urine.(2)

Signs and symptoms of hemorrhagic cystitis are also similar to the symptoms of a urinary tract infection (UTI) but are more likely going to be long-lasting and severe. These may include:

  • Feeling the need to urinate frequently
  • Experiencing pain while urinating
  • Feeling an urgent need to urinate
  • Losing bladder control

If you notice any of the hemorrhagic cystitis symptoms, you must consult your doctor before the condition progresses to grade IV. It is very rare for UTIs to cause blood urine. If you notice any blood or blood clots in your urine, it is important that you contact your doctor at once, and if you are unable to pass urine, then seek emergency medical attention at once.

Risk Factors of Hemorrhagic Cystitis

People who are undergoing chemotherapy or radiation therapy to the pelvic region are at a greater risk of developing hemorrhagic cystitis. Radiation therapy to the pelvis is used to treat cancers of the cervix, prostate, and bladder. Ifosfamide and cyclophosphamide are used for the treatment of a wide range of cancers including testicular, lymphoma, and breast cancers.

One of the greatest risks for hemorrhagic cystitis is for people who need a stem cell transplant or bone marrow transplant. This group of people may need to undergo a combination of radiation therapy and chemotherapy. This treatment is expected to lower your resistance to infection, though all these factors will ultimately increase your risk of developing hemorrhagic cystitis.

How is Hemorrhagic Cystitis Diagnosed?

If you have a history of radiation therapy or chemotherapy, then looking at your symptoms, your doctor might suspect that you have hemorrhagic cystitis. In order to diagnose hemorrhagic cystitis and also rule out any of other medical causes, including bladder stones or bladder tumor, your doctor is likely to do the following:

  • Prescribe blood tests to determine if there is anemia, infection, or any bleeding disorder
  • Prescribe urine tests to look for microscopic blood in your urine, cancer cells, or infection
  • Carry out imaging studies of your bladder with the use of an MRI, CT scan, or an ultrasound
  • Look into your bladder through cystoscopy, or a thin telescope

Treatment of Hemorrhagic Cystitis

Treatment of this condition depends on the underlying cause of hemorrhagic cystitis and also the grade of hemorrhagic cystitis. There are several treatment options available, though many are still in an experimental stage. Typically, antifungal, antibiotic, or antiviral medications are used for treating hemorrhagic cystitis that is caused by infection.(3)

Treatment options for radiation therapy or chemotherapy-related hemorrhagic cystitis are as follows:

For stage I hemorrhagic cystitis, treatment begins with intravenous fluids for increasing the output of urine in order to flush out the bladder. Medications prescribed include medication for relaxing the bladder muscles and pain medication.

If bleeding in the urine is severe or blood clots have blocked the bladder, then the treatment involves placing a thin tube known as a catheter into the bladder to flush out and dissolve these clots and also to irrigate the bladder. If however, the bleeding continues, a surgeon is going to use cystoscopy to look for areas that are bleeding and stop the bleeding with the help of a laser or electric current, a procedure known as fulguration. Side effects of fulguration are many and sometimes be serious enough to include perforation of the bladder or scarring of the bladder.

If bleeding is persistent and you are suffering heavy blood loss, then you may receive a blood transfusion.

Treatment for hemorrhagic cystitis may also include placing certain medication into the bladder, a process known as intravesical therapy. Sodium hyaluronidase is usually used as an intravesical therapy drug that helps reduce bleeding and pain.

Aminocaproic acid is another intravesical medication that is used, but a common side effect of this drug is that it may cause blood clots to develop within and can travel through the body.

In some cases, intravesical astringents are also a type of medications that are put in the bladder that cause swelling and irritation around the blood vessels to stop the bleeding. These medications can include formalin, phenol, silver nitrate, and alum. Some of the common side effects of using astringents may include decreased urine flow and swelling of the bladder.

Hyperbaric oxygen (HBO) is also another treatment that is used to treat hemorrhagic cystitis. HBO is a treatment procedure that includes breathing 100 percent oxygen while you are placed inside an oxygen chamber. This treatment works in increasing the oxygen in the body, which is likely to help with healing and also stop the bleeding. If your doctor orders HBO treatment, then you might need a daily session of HBO treatment for up to 40 to 50 sessions.

In some cases, when no other treatment is working, a treatment procedure known as embolization is another option that could be used. During this procedure, a doctor places a catheter inside a blood vessel that causes bleeding in the bladder. The catheter carries a substance that blocks the blood vessels. You are likely to experience varying degree of pain after this procedure.

In high-grade hemorrhagic cystitis, the last option left is to undergo surgery for removing the bladder, a procedure known as a cystectomy. There are many side effects of cystectomy, including infection, bleeding, and, of course, pain.

Conclusion

The outlook of HC depends on the grade and cause of the condition. hemorrhagic cystitis which is caused by infection typically has a good outlook and many people who have infectious hemorrhagic cystitis respond well to treatment and neither do they have long-term problems.

HC that is caused by cancer treatment is likely to have a different outlook. Symptoms could start within weeks, months, or even years after the treatment and could well be long-lasting. For such conditions, there are several treatment options available and in most caused hemorrhagic cystitis responds well to treatment and your symptoms are likely to improve after cancer therapy.

If none of the other treatments work, then cystectomy can help cure hemorrhagic cystitis. After a cystectomy, there are several options for undergoing reconstructive surgery to restore the flow of urine. However, needing a cystectomy for hemorrhagic cystitis is very rare.

References:  

  1. Zwaans, B.M., Nicolai, H.G., Chancellor, M.B. and Lamb, L.E., 2016. Challenges and opportunities in radiation-induced hemorrhagic cystitis. Reviews in urology, 18(2), p.57.
  2. Manikandan, R., Kumar, S. and Dorairajan, L.N., 2010. Hemorrhagic cystitis: a challenge to the urologist. Indian journal of urology: IJU: journal of the Urological Society of India, 26(2), p.159.
  3. Haldar, S., Dru, C. and Bhowmick, N.A., 2014. Mechanisms of hemorrhagic cystitis. American journal of clinical and experimental urology, 2(3), p.199.

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