Radiation cystitis: Common bloody urination after pelvic radiation

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Today we will discuss more clearly on radiation-induced bloody urination or “Radiation cystitis” in the medical term statement. There have been several patients came to see me at Urology office with the problem of bloody urine onset with history of pelvic radiation. This symptom always become a chronic issue and extremely affects patient’s quality of life.

Pelvic regional radiotherapy is a popular treatment choice in pelvic organ cancer’s control for example, prostate cancer, cervical cancer and colonic cancer. Basically, we want to trigger the beam only at the target cancer cells by without doing any damage on other organs, but in real life, it is impossible to ignoring some sort of incident. Some of off-targeted radiation will partially affects surrounding organ. Urinary bladder is also an organ which located in the pelvic area, and possibly expresses the complication in long term counted.

Radiation cystitis is reported up to 5% among the patients who have history of pelvic radiotherapy. The bleeding will not just happen once after patients complete the radiotherapy treatment, because it needs time before radiation makes chronic inflammation of the urinary bladder. There are 2 common period of times which the radiation cystitis might be occurred

• Within 3 – 6 months after radiation
• After 6 months of the after radiation – More commonly found around 10 years post-radiation therapy

The Radiation cystitis treatment plan divided into 2 phases

1. Active bleeding phase
   • Consider bladder irrigation if massive bleeding is encountered
   • Find out other correctable causes of radiation cystitis induced condition for example, urinary tract infection
   • Hospitalization when needed for patient’s stabilization
   • If the bleeding still goes on, endoscopic stop bleeding surgery is recommended

2. Stable phase
   • Hyperbaric oxygenation – Since the Radiation cystitis happen from chronic inflammation of the bladder consequence from lacking oxygenation. Place patient in hyperbaric oxygen chamber will increase bladder tissue oxygenation which leading to resolve the chronic bleeding urination. Up to 96% success rate when follow up patient at 6 months.
   • Oral medication – Pentosan polysulphate has benefit on Radiation cystitis by producing an extra bladder surface layer against the urine. The onset of acting is 1 – 8 weeks.
   • Intravesical therapy – Instillation of formalin shows response rate around 60 – 90% but reported in acute kidney injury and respiratory failure. There is a promising alternative instillation agent – Hyaluronic acid which enhances connective tissue healing process, up to 92% response rate was reported.
   • Urinary diversion – Preserved only for someone who failed from another non-invasive modality. Pseudo urinary bladder creation and stick it at the belly.

The most important key message that we must communicate with patients are, Radiation cystitis is a chronic disease which need to be treated step by step and be patient with the clinical outcome.

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