Cystitis after radiation therapy

Bladder damage can occur for a very long time after radiation therapy for up to 15 years. Approximately 15% of patients undergoing radiation therapy.

The reason is damage to small blood vessels, which leads to hypoxia and bladder wall damage. Symptoms are associated with a decrease in bladder capacity and chronic inflammation of the entire bladder wall, which causes severe bladder pain, haematuria. These symptoms are extremely troublesome and often require urinary bladder removal.

Treatment is very difficult and the results are often unsatisfactory.

It is not uncommon for standard symptomatic treatment to be insufficient. Severe cases often lead to complications requiring long-term hospitalization, sometimes with fatal outcome. In these cases, aggressive forms of therapy may be required, such as supravesical urinary diversion, embolization of bullous arteries, or cystectomy. Forecasts assume an increase in cancer incidence, therefore, a further increase in the incidence of hemorrhagic cystitis should be expected. There are currently no clear guidelines for proper treatment.

Causes of hemorrhagic cystitis

Radiation therapy is an important treatment for malignant tumors of the pelvic organs. However, the use of ionizing radiation can lead to the development of local radiation damage. The use of radiation therapy in a combined or independent version for the treatment of tumors of the pelvic organs is associated with the development of radiation injuries of adjacent organs and, in particular, the bladder, with the development of so-called radiation cystitis.

Unlike infectious inflammation of the bladder wall, radiation cystitis is a result of direct exposure to ionizing radiation and subsequent action of free radicals. Radiation injuries of the bladder began to appear in large quantities after the application of megavolt radiation therapy for malignant tumors of the pelvic organs, when, as X-ray therapy in the combined treatment of cancer of the body and neck of the uterus, bladder, prostate, and rectum, radiation injuries of the skin and subcutaneous fat were only in the field of radiation fields. The use of megavolt radiation therapy led to a significant (within 5-10%) reduction of local radiation injuries of the skin and subcutaneous fat and the appearance of previously unknown local radiation injuries of the pelvic organs: radiation cystitis, radiation rectitis, the occurrence of lymphostasis lower limbs.

Radiation damage to the bladder is usually divided into the earliest, developing during radiation therapy or in the next 3 months after it, and damage that occurs 3 months after treatment.

Symptoms of hemorrhagic cystitis

There is no reliable data on the incidence of hemorrhagic cystitis. Many factors pose a varying degree of risk of it occurring. According to selected reports, the incidence reaches up to 100% in patients after radiation or chemotherapy.

Hemorrhagic cystitis can manifest as hematuria or hematuria is hemorrhagic with clots. Depending on the severity of bleeding and pain, mild, moderate, and severe inflammation is distinguished. Although most studies focus on severe (Droller grade III and IV) hemorrhagic cystitis, stage I disease can also cause bothersome symptoms such as pollakiuria, urgency, and lower abdominal pain.

Bladder therapy in the treatment of radiation cystitis

The indications for treatment depend on the degree of symptoms present and the patient’s desire. Grade I and II symptoms require treatment only if the patient is bothered by them. Symptoms can be controlled medically. The observation is acceptable. Grade III control and more severe clinical manifestations depend on the type of symptom. Urinary dysfunction can be medically controlled if the patient wishes. Urodynamic studies may be necessary if more severe symptoms are present. Most symptoms can be assessed by history and physical examination. Macroscopic hematuria is an indication to assess fluid volume, clotting, and the need for transfusions. Cystoscopy and renal imaging are also indicated to rule out other causes of genitourinary bleeding. Fistula formation requires surgery. The contracted bladder and incontinence require evaluation to determine the degree of disability, bladder compromise, and surgical potential. Surgery is contraindicated for treating severe complications that do not respond to medical supervision.

The bladder has a protective barrier, it is a hydrophilic mucosa that prevents harmful substances in the urine from penetrating into the deeper layers of the bladder wall. It consists of GAG glycosaminoglycans, which include hyaluronic acid and particles containing a sulfate group, including chondroitin sulfate.

Chondroitin sulfate

There are many studies assessing the use of chondroitin sulfate in patients with bladder pain / interstitial syndrome after cystitis. Mostly, less onerous symptoms and good treatment tolerance were reported. Chondroitin sulfate installations further reduced detrusor hyperactivity symptoms during radiation therapy.

Medical studies have shown that the use of standard drugs (Dimexide, Hepon and superoxide dismutase) has a different focus. So, with severe fibrosis of the bladder wall, preference should be given to the use of Dimexide; with a pronounced infectious process, the use of Hepon was most effective, and in patients with hematuria and a violation of the integrity of the bladder mucosa (erosive or ulcerative necrotic cystitis), the use of superoxide dismutase is most effective. The choice of treatment should be based on subjective complaints and objective research methods.


The article is written by licensed urologists: Dr. David M. Kaufman and David M. Weiner, MD. If you have any questions after reading the article, you can contact us by asking a question in the feedback form

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