Andrew Siegel MD 2/1/2020
It’s an exciting sports weekend! I’m hoping for that amazing Austrian tennis star, Dominic Thiem over the incredible Novak Djokovic in the Aussie Open and for Patrick Mahomes and the KC Chiefs over the SF 49ers.
Each treatment option for prostate cancer is a “double-edged sword” with benefits and risks that must be weighed carefully before making a decision about what is the most appropriate treatment for any individual patient. Radiation therapy is a time-honored, highly effective, most often curative treatment with one of the advantages commonly stated as “less side effects than surgery.” However, it is important to know that as effective and safe as radiation therapy is, it is not without potential side effects and complications that may occur in the occasional patient. One of the adverse occurrences that may occur years following treatment is radiation-induced hemorrhagic cystitis, an often-challenging problem that is the topic of today’s entry.
Radiation cystitis typically causes blood in the urine and irritative bladder symptoms—urinary urgency, frequency, burning, and discomfort. This consequence of pelvic radiation therapy occurs in less than 5% of men who have undergone radiation as treatment for prostate cancer. It may also occur after pelvic radiation for other malignancies, including bladder, colon and uterine cancers. It is a delayed complication, typically occurring 5 or more years following completion of the radiation.
In the early, acute phase, radiation causes inflammation and edema (tissue swelling). In the later, chronic phase, it induces microvascular damage (damage to the smallest blood vessels), tissue hypoxemia (low concentrations of oxygen in the radiated tissues) and fibrosis (scarring). This microvascular damage, a.k.a. “obliterative endarteritis,” results in fragile vessels that bleed with little provocation. On cystoscopy (examination of the inside of the bladder with a tiny, lighted scope), radiation cystitis has a classic appearance of vibrantly colored, exuberant, serpentine blood vessels.
Radiation cystitis seen via cystoscopy
Bleeding from radiation cystitis can range from mild to severe. It may be provoked by straining with bowel movements and strenuous physical activities, but may also occur spontaneously, without provocation. In many cases, it is intermittent and minor and can be managed with hydration, restriction of physical activities and avoidance of straining. However, at the other extreme, the bleeding can be significant, resulting in anemia and the need for transfusion, hospitalization and trips to the operating room with potential complications from the treatment.
Treatment of Radiation Cystitis
Radiation cystitis can be a challenging problem that often requires a combination of treatments. If hydration and activity restriction fail to stem the problem, the next step is usually a catheter placement with irrigation of the urinary bladder. If this is not successful, cystoscopy with evacuation of clots and cauterization (electrical coagulation) of bleeding sites is often required. If this fails to staunch the bleeding, there are a variety of caustic and coagulative agents that can be instilled in the bladder in an effort to stop the bleeding. These include the following: aminocaproic acid (Amicar); formalin; alum; and silver nitrate. Each of these chemicals offer certain advantages and disadvantages. Hyperbaric oxygen therapy—placement in a high-pressure oxygen chamber—is another option that can be successful at times.
Life-threatening urinary tract bleeding is a rare but serious complication. If it fails to respond to the aforementioned treatments, a variety of options may need to be employed. Hyper-selective embolization is a procedure performed by interventional radiology in which the specific blood vessels responsible for the bleeding are occluded. Infrequently, refractory hemorrhagic radiation cystitis that does not respond to lesser measures will require surgical removal of the urinary bladder and diversion of the ureters (tubes that conduct urine from the kidneys to the bladder) to a piece of intestine that is brought out through the abdominal wall.
Complications of Treatments of Radiation Cystitis
There may be after-effects successful management of radiation cystitis . Urinary tract infections are not uncommon occurrences and are typically easily managed with antibiotics, although on occasion, a systemic and potentially life-threatening infection that originates in the urinary tract—urosepsis—can occur. Scarring in the urethral channel may occur, necessitating urethral dilations or alternative procedures to open up the scarred passageway. Hydronephrosis (fullness and dilation of the inner part of the kidney that collects the urine) may occur as a consequence of treatment of radiation cystitis with caustic agents as well as a consequence of bladder scarring from the radiation cystitis itself. Caustic agents also have the potential of incurring injuries to the functional part of the kidney that produces the urine.
Wishing you the best of health,
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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.
The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families
Video trailer for Prostate Cancer 20/20
Preview of Prostate Cancer 20/20
Andrew Siegel MD Amazon author page
Prostate Cancer 20/20 on Apple iBooks
PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families is now on sale at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours).
Dr. Siegel’s other books:
PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food
MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health
THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health
Tags: Andrew Siegel MD, hyperbaric oxygen therapy, prostate cancer, Prostate Cancer 20/20, radiation cystitis, radiation therapy
Our Greatest Wealth Is Health 
March 7, 2020 at 9:56 AM |
[…] burning or painful urination, urinary frequency and difficulty urinating. Urinary bleeding due to radiation cystitis is oftentimes provoked by straining, particularly with bowel movements, as well as participation in […]
June 6, 2020 at 7:04 AM |
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