Hemorrhagic cystitis (HC) is a medical condition characterized by inflammation and bleeding in the bladder. This condition can be quite painful and may lead to various complications if left untreated. Hemorrhagic cystitis can be caused by several factors, including viral infections, such as adenovirus or cytomegalovirus, bacterial infections, certain medications (such as chemotherapy drugs or certain antibiotics), radiation therapy, and exposure to certain chemicals.

It’s essential for individuals experiencing symptoms of HC to seek medical attention promptly for proper diagnosis and treatment to prevent complications and ensure optimal recovery.

What is hemorrhagic cystitis?

Hemorrhagic cystitis is a medical condition characterized by inflammation and bleeding in the bladder. It can occur due to various causes, including infections, certain medications, radiation therapy, or exposure to certain chemicals. The inflammation and damage to the bladder lining result in the leakage of blood into the urine, leading to symptoms such as blood in the urine (hematuria), pain or discomfort in the lower abdomen, frequent and urgent need to urinate, burning sensation during urination, difficulty urinating, and in some cases, fever.

This condition can be acute or chronic and may vary in severity. Acute hemorrhagic cystitis often resolves on its own or with appropriate treatment, while chronic hemorrhagic cystitis may require ongoing management to control symptoms and prevent complications.

Treatment for HC depends on the underlying cause and severity of symptoms. It may include medications to manage pain and inflammation, antibiotics if there is an underlying bacterial infection, bladder irrigation to remove blood clots and debris, or interventions to address the underlying cause, such as adjusting or discontinuing certain medications or treatments.

Preventive measures for hemorrhagic cystitis may include staying hydrated, avoiding irritants such as alcohol and caffeine, practicing good hygiene, and taking precautions to prevent infections.

Overall, HC can be a painful and distressing condition, but with proper diagnosis and management, most individuals can experience relief from symptoms and improve their quality of life.

Causes of  hemorrhagic cystitis

Hemorrhagic cystitis can be caused by various factors, including:

• Infections: Viral infections such as adenovirus, cytomegalovirus (CMV), or BK virus, as well as bacterial infections like Escherichia coli (E. coli), can lead to inflammation and bleeding in the bladder.
• Medications: Certain medications, particularly chemotherapy drugs such as cyclophosphamide and ifosfamide, can cause hemorrhagic cystitis as a side effect. Other medications, including some antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs), may also contribute to bladder irritation and bleeding.
• Radiation therapy: Radiation treatment for cancers in the pelvic region, such as bladder cancer or prostate cancer, can damage the lining of the bladder and lead to hemorrhagic cystitis.
• Chemical exposure: Exposure to certain chemicals, such as those used in industrial settings or in the production of dyes and paints, can irritate the bladder and cause inflammation and bleeding.
• Catheter use: Prolonged use of urinary catheters, particularly in hospitalized patients or those with spinal cord injuries, can increase the risk of developing hemorrhagic cystitis due to irritation and trauma to the bladder lining.
• Bladder trauma: Trauma to the bladder, such as from bladder surgery or injury, can cause inflammation and bleeding, leading to hemorrhagic cystitis.
• Autoimmune disorders: In rare cases, autoimmune conditions such as systemic lupus erythematosus (SLE) or autoimmune hemolytic anemia may cause inflammation and damage to the bladder, resulting in hemorrhagic cystitis.
• Rare genetic disorders: Certain rare genetic disorders, such as hemorrhagic cystitis associated with adenovirus infection in immunocompromised individuals, can also lead to this condition.

Clasification of HC

Hemorrhagic cystitis can be classified based on various factors, including the underlying cause, severity, and duration of the condition. Here are some common classifications:

By Cause:

• Infectious Hemorrhagic Cystitis: Caused by viral or bacterial infections such as adenovirus, cytomegalovirus (CMV), or Escherichia coli (E. coli).
  • Chemotherapy-Induced Hemorrhagic Cystitis: Occurs as a side effect of certain chemotherapy drugs, particularly cyclophosphamide and ifosfamide.
  • Radiation-Induced Hemorrhagic Cystitis: Resulting from radiation therapy for pelvic cancers, such as bladder or prostate cancer.
  • Drug-Induced Hemorrhagic Cystitis: Caused by medications other than chemotherapy drugs, such as certain antibiotics or nonsteroidal anti-inflammatory drugs (NSAIDs).
  • Idiopathic Hemorrhagic Cystitis: When the exact cause of the condition is unknown.

By Severity:

• Mild Hemorrhagic Cystitis: Characterized by minimal bleeding and discomfort, often resolving with minimal intervention or supportive care.
  • Moderate Hemorrhagic Cystitis: Involving more significant bleeding and discomfort, requiring medical intervention and management of symptoms.
  • Severe Hemorrhagic Cystitis: Marked by extensive bleeding, severe pain, and potential complications, necessitating immediate medical attention and intensive treatment.

By Duration:

• Acute Hemorrhagic Cystitis: Develops suddenly and typically resolves within a few days to weeks with appropriate treatment.
  • Chronic Hemorrhagic Cystitis: Persists over a longer period, often recurring or remaining unresolved despite treatment, requiring ongoing management and monitoring.

By Complications:

• Complicated Hemorrhagic Cystitis: Associated with complications such as urinary retention, bladder ulcers, recurrent infections, or bladder dysfunction.
  • Uncomplicated Hemorrhagic Cystitis: Occurs without significant complications, with symptoms primarily limited to bladder inflammation and bleeding.

Symptoms of HC

The symptoms of hemorrhagic cystitis can vary in severity and may include:

• Blood in the urine (hematuria): This is the hallmark symptom of hemorrhagic cystitis. The urine may appear pink, red, or brownish in color due to the presence of blood. The amount of blood can range from small traces to significant amounts.
• Pain or discomfort: Individuals with hemorrhagic cystitis may experience pain or discomfort in the lower abdomen, pelvis, or bladder area. This pain may be dull or cramp-like and can vary in intensity.
• Frequent and urgent urination: There may be an increased urge to urinate, along with a feeling of urgency, even when the bladder is not full. This symptom is often accompanied by a decreased ability to hold urine for extended periods.
• Burning sensation during urination: Hemorrhagic cystitis can cause irritation and inflammation of the bladder lining, leading to a burning or stinging sensation when passing urine.
• Difficulty urinating: Some individuals may experience difficulty initiating urination or a weakened urine stream due to bladder irritation or obstruction caused by blood clots or inflammation.
• Bladder spasms: Hemorrhagic cystitis can cause involuntary contractions or spasms of the bladder muscles, leading to discomfort or pain.
• Fever: In some cases, particularly when hemorrhagic cystitis is caused by an underlying infection, individuals may develop a fever along with other symptoms of systemic illness, such as fatigue or malaise.

Diagnosis

The diagnosis of hemorrhagic cystitis typically involves a combination of medical history review, physical examination, laboratory tests, and imaging studies. Here’s an overview of the diagnostic process:

Medical History and Physical Examination: The healthcare provider will start by taking a detailed medical history, including any recent illnesses, infections, medications, or treatments that could be associated with HC. They will also inquire about symptoms such as blood in the urine, pain, or difficulty urinating. A physical examination may include palpation of the abdomen and pelvic area to assess for tenderness or abnormalities.

Urine Tests:

• Urinalysis: A urine sample will be collected and analyzed to check for the presence of blood, white blood cells (indicating inflammation or infection), and other abnormalities.
  • Urine Culture: If an infection is suspected, a urine culture may be performed to identify the type of bacteria or virus causing the infection and determine the appropriate antibiotic or antiviral treatment.

Imaging Studies:

• Ultrasound: An ultrasound of the bladder and urinary tract may be performed to assess for abnormalities such as bladder stones, tumors, or structural issues.
  • Cystoscopy: In some cases, a cystoscopy may be recommended, where a thin, flexible tube with a camera (cystoscope) is inserted through the urethra into the bladder to visualize the bladder lining directly. This allows the healthcare provider to inspect for signs of inflammation, bleeding, or other abnormalities.

Additional Tests:

• Blood Tests: Blood tests may be conducted to assess kidney function, rule out systemic infections, or check for underlying conditions that could contribute to hemorrhagic cystitis.
  • Biopsy: In rare cases where the cause of hemorrhagic cystitis is unclear or if there are suspicious lesions in the bladder, a biopsy of the bladder lining may be recommended to obtain tissue samples for further examination.

Once a diagnosis of HC is confirmed, the underlying cause will be identified and appropriate treatment initiated. The diagnostic process may vary depending on individual circumstances and the suspected cause of the condition. It’s essential for individuals experiencing symptoms of hemorrhagic cystitis to seek medical evaluation promptly for proper diagnosis and management.

Complications

HC can lead to several complications, particularly if left untreated or if the underlying cause is not effectively managed. Some potential complications include:

• Anemia: Chronic or severe bleeding in the bladder can lead to a significant loss of red blood cells, resulting in anemia. Anemia can cause symptoms such as fatigue, weakness, and shortness of breath.
• Urinary Tract Infections (UTIs): The presence of blood in the urine and bladder irritation can increase the risk of developing urinary tract infections. UTIs can cause symptoms such as frequent urination, burning during urination, and fever.
• Bladder Dysfunction: Chronic inflammation and damage to the bladder lining can lead to bladder dysfunction, including urinary retention (inability to completely empty the bladder), urinary urgency and frequency, and difficulty controlling urine flow.
• Bladder Stones: Recurrent or prolonged inflammation and bleeding in the bladder can lead to the formation of bladder stones (calculi). These stones can cause pain, urinary obstruction, and increase the risk of urinary tract infections.
• Bladder Fibrosis and Scarring: Chronic inflammation and tissue damage in the bladder can lead to the formation of scar tissue (fibrosis) and bladder wall thickening. This can impair bladder function and lead to urinary symptoms such as hesitancy, weak stream, and incomplete emptying.
• Renal Damage: Severe or untreated cases of hemorrhagic cystitis can potentially lead to kidney damage or renal failure, particularly if there is urinary obstruction or recurrent urinary tract infections that ascend to the kidneys.
• Hemorrhage and Shock: In rare cases, severe hemorrhagic cystitis can lead to life-threatening bleeding (hemorrhage) and shock, characterized by low blood pressure, rapid heart rate, and organ dysfunction.

Prognosis

The prognosis of HC depends on several factors, including the underlying cause, severity of symptoms, promptness of diagnosis, and effectiveness of treatment. In many cases, hemorrhagic cystitis is acute and resolves with appropriate management, leading to a good prognosis. However, in some instances, particularly when the condition is chronic or severe, complications may arise, affecting the long-term outlook.

Here are some factors that can influence the prognosis of hemorrhagic cystitis:

• Underlying Cause: The prognosis may vary depending on the cause of hemorrhagic cystitis. For example, cases caused by viral infections may resolve once the infection clears, while those induced by chemotherapy or radiation therapy may require ongoing management.
• Severity of Symptoms: The severity of symptoms, such as the extent of bleeding, pain, and bladder dysfunction, can affect the prognosis. Mild cases with minimal symptoms tend to have a better prognosis compared to severe cases with significant bleeding and complications.
• Complications: The development of complications such as urinary tract infections, bladder stones, renal damage, or bladder dysfunction can impact the prognosis. Prompt recognition and management of complications are essential to prevent long-term sequelae.
• Response to Treatment: The effectiveness of treatment in controlling symptoms, resolving underlying infections, and preventing recurrence play a crucial role in determining the prognosis. Some cases may require multiple treatment modalities or ongoing management to achieve symptom control and prevent relapse.
• Individual Health Factors: The overall health and immune function of the individual can influence their ability to recover from hemorrhagic cystitis. Patients with underlying health conditions or compromised immune systems may have a poorer prognosis and may require more intensive management.

In general, with appropriate medical care and management, many individuals with hemorrhagic cystitis can experience improvement in symptoms and achieve a good long-term prognosis. However, close monitoring, adherence to treatment recommendations, and preventive measures may be necessary to minimize the risk of recurrence and complications. It’s essential for individuals with hemorrhagic cystitis to work closely with their healthcare providers to optimize their treatment plan and ensure the best possible outcome.

Prevention against for HC

Prevention strategies for this disease may vary depending on the underlying cause. However, here are some general preventive measures that may help reduce the risk of developing this condition:

• Stay Hydrated: Drinking plenty of fluids helps dilute urine and may reduce bladder irritation. Aim to drink enough water throughout the day to maintain adequate hydration.
• Good Hygiene Practices: Practicing good hygiene, including proper genital and perineal care, can help prevent urinary tract infections, which are a common cause of hemorrhagic cystitis.
• Avoid Irritants: Limit or avoid exposure to substances that can irritate the bladder, such as caffeine, alcohol, spicy foods, and certain medications known to exacerbate bladder symptoms.
• Monitor Medications: If you’re prescribed medications known to cause hemorrhagic cystitis, such as certain chemotherapy drugs or antibiotics, discuss preventive measures with your healthcare provider. They may recommend additional medications or interventions to reduce the risk of bladder damage.
• Protective Measures During Radiation Therapy: If undergoing radiation therapy in the pelvic region, discuss preventive strategies with your healthcare team. They may recommend bladder-protective measures such as hyperhydration or the use of certain medications (e.g., amifostine) to minimize bladder damage.
• Maintain a Healthy Immune System: A strong immune system can help fight off infections and reduce the risk of viral or bacterial causes of hemorrhagic cystitis. Practice healthy habits such as regular exercise, a balanced diet, adequate sleep, and stress management to support immune function.
• Prompt Treatment of Infections: If you develop symptoms of a urinary tract infection, such as burning with urination or increased urinary frequency, seek prompt medical attention for diagnosis and treatment. Untreated infections can lead to complications such as hemorrhagic cystitis.

• Follow Healthcare Provider Recommendations: If you have a medical condition or are undergoing treatments that increase your risk of hemorrhagic cystitis, such as cancer or chemotherapy, closely follow your healthcare provider’s recommendations for preventive measures and monitoring.Formun Üstü

Treatment HC

The treatment of hemorrhagic cystitis depends on the underlying cause, severity of symptoms, and individual patient factors. Here are some common treatment approaches:

Addressing Underlying Cause:

• If disease is caused by a viral infection (e.g., adenovirus, cytomegalovirus), antiviral medications may be prescribed.
  • For cases induced by bacterial infections, antibiotics may be necessary to treat the underlying infection.
  • If medications such as chemotherapy drugs are causing hemorrhagic cystitis, the dosage may be adjusted, or alternative medications may be considered.

Symptomatic Management:

• Pain relief: Nonsteroidal anti-inflammatory drugs (NSAIDs) or prescription pain medications may be used to alleviate discomfort.
  • Bladder spasm control: Medications such as anticholinergics or muscle relaxants may help relieve bladder spasms and reduce urinary urgency.
  • Bladder irrigation: In severe cases, bladder irrigation with saline or other solutions may be performed to help remove blood clots and debris from the bladder and alleviate symptoms.
  • Intravesical therapy: In some cases, medications such as alum or silver nitrate may be instilled directly into the bladder to help control bleeding and inflammation.

Supportive Care:

• Hydration: Drinking plenty of fluids can help dilute urine and reduce bladder irritation.
  • Bladder rest: Avoiding irritants such as caffeine, alcohol, and spicy foods may help reduce bladder irritation.
  • Bladder training: Techniques such as scheduled voiding and pelvic floor exercises may help improve bladder function and control symptoms.

Procedures and Interventions:

• Cystoscopy: In some cases, a cystoscopy may be performed to directly visualize the bladder and perform interventions such as clot evacuation or cauterization of bleeding vessels.
  • – In rare cases of severe or refractory hemorrhagic cystitis, surgical procedures such as bladder fulguration (burning of bleeding areas) or bladder augmentation may be considered.

Preventive Measures:

• In cases where hemorrhagic cystitis is induced by chemotherapy or radiation therapy, preventive measures such as hyperhydration or the use of certain medications (e.g., mesna) may be employed to reduce the risk of bladder damage.
  • Good hygiene practices and avoiding exposure to known irritants or infectious agents can help prevent recurrent episodes of hemorrhagic cystitis.

Treatment for hemorrhagic cystitis should be individualized based on the specific circumstances of each patient and may require a multidisciplinary approach involving urologists, oncologists, infectious disease specialists, and supportive care providers. Close monitoring and follow-up are essential to assess treatment response, manage complications, and optimize outcomes.

Summary

Hemorrhagic cystitis is a medical condition characterized by inflammation and bleeding in the bladder. It can be caused by various factors such as viral or bacterial infections, certain medications (particularly chemotherapy drugs), radiation therapy, or chemical exposure. Symptoms may include blood in the urine (hematuria), pain or discomfort in the lower abdomen, frequent and urgent urination, burning sensation during urination, and difficulty urinating. Diagnosis involves a combination of medical history review, physical examination, urine tests, and imaging studies. Treatment depends on the underlying cause and severity of symptoms and may include addressing the underlying infection, managing symptoms with medications, bladder irrigation, or surgical interventions in severe cases. With prompt diagnosis and appropriate management, many individuals with hemorrhagic cystitis can experience relief from symptoms and achieve a good prognosis. However, close monitoring and follow-up are necessary to prevent complications and optimize outcomes.

Prof. Dr. Emin ÖZBEK

Urologist

Istanbul- TURKEY