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Radiation-induced hemorrhagic cystitis

Key sources
The following summarized guidelines for the evaluation and management of radiation-induced hemorrhagic cystitis are prepared by our editorial team based on guidelines from the Canadian Urological Association (CUA 2019) and the Journal of Clinical Urology (JCU 2014).


1.Screening and diagnosis

Differential diagnosis: assess patients with post-radiation hematuria to identify or exclude other pathological factors that may explain or contribute to the patient's symptoms.
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  • Diagnosis

2.Diagnostic investigations

Initial assessment: elicit careful history, perform physical examination and obtain laboratory examination as the basic assessment.

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  • Diagnostic imaging

3.Diagnostic procedures

Cystoscopy: perform at least one initial cystoscopy with or without fulguration of suspect lesions and biopsy of any lesion concerning for malignancy for diagnostic and therapeutic purposes in all patients with post-radiation hematuria.

4.Respiratory support

Hyperbaric oxygen therapy: as per CUA 2019 guidelines, consider offering hyperbaric oxygen therapy for early management of patients with RHC failed cystoscopy and fulguration. Recognize that significant resource and expertise requirements may limit its use.

5.Medical management

General principles
Ensure a multimodality stepwise approach for the treatment of patients with hemorrhagic cystitis.
Decide on choice of therapy depending on the degree of hematuria.

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  • Supportive therapy

  • Sodium pentosan polysulfate

  • Tranexamic acid

  • Other systemic agents

  • Management of severe hemorrhagic cystitis

6.Therapeutic procedures

Alum irrigation: consider performing bladder irrigation with alum in patients with RHC. Recognize that it is a practical, easily applied and generally well-tolerated procedure with a comparatively acute onset of action. Use special caution in patients with poor renal function.

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  • Intravesical hyaluronic acid

  • Intravesical formalin

  • Other intravesical agents

  • Clot removal

  • Endoscopic hemostasis

  • Laser therapy

  • Transarterial embolization

7.Surgical interventions

Cystectomy and urinary diversion: as per CUA 2019 guidelines, perform urinary diversion with or without cystectomy only in patients with RHC failed previously available therapy. Recognize and inform patients about the high morbidity and mortality of the procedure before proceeding with surgery.

8.Preventative measures

Prophylaxis: consider administering sodium hyaluronate 40 mg/50 ml in patients at increased risk of hemorrhagic cystitis, such as patients receiving external beam radiation therapy and brachytherapy for cervical or endometrial cancer.
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