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Management of radiation cystitis

Abstract

Acute radiation cystitis occurs during or soon after radiation treatment. It is usually self-limiting, and is generally managed conservatively. Late radiation cystitis, on the other hand, can develop from 6 months to 20 years after radiation therapy. The main presenting symptom is hematuria, which may vary from mild to severe, life-threatening hemorrhage. Initial management includes intravenous fluid replacement, blood transfusion if indicated and transurethral catheterization with bladder washout and irrigation. Oral or parenteral agents that can be used to control hematuria include conjugated estrogens, pentosan polysulfate or WF10. Cystoscopy with laser fulguration or electrocoagulation of bleeding points is sometimes effective. Injection of botulinum toxin A in the bladder wall may relieve irritative bladder symptoms. Intravesical instillation of aluminum, placental extract, prostaglandins or formalin can also be effective. More-aggressive treatment options include selective embolization or ligation of the internal iliac arteries. Surgical options include urinary diversion by percutaneous nephrostomy or intestinal conduit, with or without cystectomy. Hyperbaric oxygen therapy (HBOT) involves the administration of 100% oxygen at higher than atmospheric pressure. The reported success rate of HBOT for radiation cystitis varies from 60% to 92%. An important multicenter, double-blind, randomized, sham-controlled trial to evaluate the effectiveness of HBOT for refractory radiation cystitis is currently being conducted.

Key Points

  • Late radiation cystitis can cause severe, life-threatening hematuria

  • Oral or parenteral agents to control hematuria resulting from late radiation cystitis include conjugated estrogens, pentosan polysulfate and WF10

  • Intravesical agents that can be used include alum, placental extract, prostaglandins and formalin

  • Less-invasive interventions include cystoscopic fulguration of bleeding points, urinary diversion by percutaneous nephrostomy, and embolization of the internal iliac arteries

  • Surgical options include urinary diversion with or without cystectomy

  • Hyperbaric oxygen therapy has been reported to yield high success rates, with a low risk of complications

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Figure 1: Hyperbaric oxygen chambers.
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Smit, S., Heyns, C. Management of radiation cystitis. Nat Rev Urol 7, 206–214 (2010). https://doi.org/10.1038/nrurol.2010.23

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