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Course: Oncology Nursing

Topic: Nursing Management of

Oncological Emergency - Hemorrhagic Cystitis

The Nurses International Community

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Module Goals

Learners will be able to:

Explain the underlying pathophysiology of hemorrhagic cystitis.
Describe the scope of the problem including the incidence, etiology and risk factors for this oncologic emergency.
List the clinical manifestations that are associated with this emergency situation.
Explain the nursing assessment for hemorrhagic cystitis including relevant diagnostic tests.
Characterize the nursing interventions and supportive care important to address this problem in a timely and effective manner.

Contact info: info@nursesinternational.org

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Definition

“Hemorrhagic cystitis (HC) is an inflammatory process characterised by diffuse bladder mucosal inflammation with haemorrhage involving the whole bladder.”

NSW, 2020

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Risk Factors of Hemorrhagic Cystitis

HC may be treatment-related:

antineoplastic drugs e.g. cyclophosphamide and ifosfamide
intravesical therapy
radiotherapy to the pelvic area
infection following immunosuppression and associated with allogeneic transplant e.g. BK virus, adenovirus,

Other risk factors for developing HC include:

patient’s hydration status
patient’s urine frequency and output
concomitant urotoxic drugs

NSW, 2020

Contact info: info@nursesinternational.org

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Pathophysiology of Hemorrhagic Cystitis

Certain chemotherapy drugs (Cyclophosphamide and Ifosfamide)are broken down by the body into substances (acrolein) that can be harmful.
Acrolein can mechanically cleave proteins and break strands of DNA causing tissue cell death.
Acrolein excreted from the body through the bladder can cause irritation to the lining of the bladder.
Irritation can be severe and cause ulceration resulting in significant bleeding.

Haldar, Dru & Browmick, 2014

Contact info: info@nursesinternational.org

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Causes of Hemorrhagic Cystitis

Brian, Nelson & Mrinal, 2021

HC is most common in patients treated with:

Ifosfamide and high-dose cyclophosphamide in the setting of bone and soft tissue sarcoma.
Hematopoietic cell transplantation
Radiation therapy (RT) when the bladder is within the radiation treatment field.

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Causes of Hemorrhagic Cystitis

Manikandan, Kumar & Dorairajan, 2010

The other causes of HC are

Environmental toxins:

Aniline dyes
Toluidine
Chlordimeform
Ether

Infections:

Viral: adenovirus, BK virus, herpes virus, cytomegalovirus
Bacterial: Escherichia coli, Staphylococcus saprophyticus, Klebsiella
Parasitic: schistosomiasis and Echinococcosis

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Other Causes of Hemorrhagic Cystitis

Other systemic conditions include:

Amyloidosis
Immune Inflammatory diseases like Systemic lupus erythematosus, Rheumatoid arthritis and Crohn’s disease
Boon’s disease

Manikandan, Kumar & Dorairajan, 2010

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Case Study/Critical Thinking Question/What would the Nurse do?

Mr Bachhan is a cancer patient. He is getting treatment with chemotherapy for his sarcoma and during his treatment period he developed hematuria and was diagnosed with hemorrhagic cystitis.

What could be the most common cause for HC in his case? (Select all that apply)

Ifosfamide
Cyclophosphamide
Infection
Environmental toxin

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Sign and Symptoms of Hemorrhagic Cystitis

The clinical presentation of HC in cancer patient is highly variable:

Mild hematuria
Gross hematuria (presence of pink, red, or brown urine) with clots
The urine loses translucent appears ~ can look similar to ketchup
Urinary urgency and frequent urination of only small volumes
Sensation of incomplete bladder emptying
Painful burning sensations

Brian, Nelson & Mrinal, 2021

Contact info: info@nursesinternational.org

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Sign and Symptoms of Hemorrhagic Cystitis

In men, bladder spasms may produce severe referred pain in the glans penis.
Flank or back pain should raise the possibility of upper urinary tract or bladder outlet obstruction.
In cases of more severe bleeding, patients may present with urinary retention secondary to blood clots obstructing the bladder neck also known as "clot retention".

Brian, Nelson & Mrinal, 2021

Contact info: info@nursesinternational.org

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Sign and Symptoms of Hemorrhagic Cystitis

For patients receiving cyclophosphamide or ifosfamide, bleeding usually develops:

24 to 48 hours after a single dose and typically lasts four to five days

The interval between the onset of HC and prior radiation therapy (RT):

Varies from months to years after treatment
HC can appear as late as 10 or 20 years after treatment

Brian, Nelson & Mrinal, 2021

Contact info: info@nursesinternational.org

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Clot removed from the bladder in a patient with

severe radiation-induced hemorrhagic cystitis

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Grading of Hemorrhagic Cystitis Symptoms

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Case Study/Critical Thinking Question/What would the Nurse do?

Miss Rai is a nurse in an oncology ward. She has been caring for a client who is getting treatment with the chemo agent cyclophosphamide. After a few days of treatment, the client developed hemorrhagic cystitis.

What are the sign and symptoms of HC? (Select all that apply)

Hematuria
Dysuria
Flank pain
Frequency of urination

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Diagnosis of Hemorrhagic Cystitis

Brian, Nelson & Mrinal, 2021

Components of basic assessment should include the following:

History
Physical Examination
Urinalysis
Urine Culture
Cystoscopy under general anesthesia
Cytology if indicated

The diagnosis may be supported by a computed tomography (CT) urogram or magnetic resonance imaging (MRI) scan of the pelvis and abdomen, as well as relevant tumour markers.

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Diagnosis of Hemorrhagic Cystitis

History:

A through history of the patient’s status includes:

Any prior urologic diagnoses or surgeries
Chemotherapy and radiation therapy [RT] treatments
Review of medications: Does the patient take anticoagulants, over-the-counter and/or nontraditional medications

An exhaustive history of past and present medications is important since some chemotherapeutic agents may produce cystitis years after exposure (eg, busulfan)

Brian, Nelson & Mrinal, 2021

Contact info: info@nursesinternational.org

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Diagnosis of Hemorrhagic Cystitis

Physical examination:

Should performed on all patients with HC (including a pelvic examination)

Laboratory tests:

Includes a urinalysis and urine culture to exclude infection.
If the patient has received chemotherapy, clotting disorders should be considered and coag studies should be done.
Other laboratory evaluations should include haemoglobin, complete blood count, blood urea, serum creatinine and coagulation profile.

Brian, Nelson & Mrinal, 2021

Contact info: info@nursesinternational.org

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Diagnosis of Hemorrhagic Cystitis

Cystoscopy:

For more severe cases, or if the diagnosis is in question, cystoscopy is indicated to evaluate:

For bladder tumors
Potentially localize the bleeding

HC is typically characterized on cystoscopy by diffuse oozing of the bladder mucosa with neovascularization and telangiectasias.
In cases of severe bleeding, cystoscopy under anesthesia may also allow for cauterization of bleeding vessels and clot evacuation.

Brian, Nelson & Mrinal, 2021

Contact info: info@nursesinternational.org

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Diagnosis of Hemorrhagic Cystitis

Brian, Nelson & Mrinal, 2021

Imaging studies:

CT Scan is needed to evaluate for:

Renal or ureteral tumors
Bladder or other pelvic masses
Urolithiasis (kidney stones)

In severe HC, this allows for an assessment of the degree of clot burden in the bladder.

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Case Study/Critical Thinking Question/What would the nurse do?

In an oncology ward, a client had hematuria, dysuria, flank pain, and frequency of urine. It was suspected that the patient had hemorrhagic cystitis. What are the other diagnostic testing that confirm HC?

Urine analysis
Urine Culture
Cystoscopy
Physical Examination

Contact info: info@nursesinternational.org

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Prevention of Hemorrhagic Cystitis

The best treatment for hemorrhagic cystitis (HC) is prevention

For cancer patients receiving ifosfamide and high-dose cyclophosphamide:

Nurses may give patients saline diuresis and mesna to prevent HC.
Provide close monitoring during treatment and report any early indications of HC to the medical team for prompt treatment.
Instruct patient to drink one large glass of cranberry juice which may help to reduce the risk of HC.

Brian, Nelson & Mrinal, 2021

Contact info: info@nursesinternational.org

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Prevention of Hemorrhagic Cystitis

Mesna:

Is a thiol drug that inactivates acrolein in the urine to reduce the risk of bladder toxicity due to cyclophosphamide and ifosfamide.
Is an effective uro-protective agent in cancer patients receiving both ifosfamide and high-dose cyclophosphamide.
Nurses administer mesna according to protocol.
Mesna must be present in the bladder at the time of chemotherapy administration and for up to 12 to 24 hrs in order to be effective.
Mesna can be given intravenously (either continuous or bolus), subcutaneously (continuous) or orally.

Brian, Nelson & Mrinal, 2021

Contact info: info@nursesinternational.org

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Prevention of Hemorrhagic Cystitis

Nurses instruct patients to drink at least 2 L of fluid a day and to void at first sensation.
Oral fluids should be ingested prior to sleep, and patients should awaken once during the night to empty the bladder.
Men should be encouraged to stand to void rather than using a bedside urinal in a recumbent position (want to avoid incomplete emptying of the bladder.)

Brian, Nelson & Mrinal, 2021

Contact info: info@nursesinternational.org

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Case Study/Critical Thinking Question/What would the nurse do?

Mr. Alex is 45 yrs old and has been diagnosed with sarcoma. He ris eceiving chemotherapy with high dose of cyclophosphamide. What are the most common practices to prevent hemorrhagic cystitis (HC)? (Select all that apply)

Encouraged to drink more fluids
Forced saline diuresis
Mesna at the time of chemotherapy
Men should be encouraged to stand to void rather than using bed pan

Contact info: info@nursesinternational.org

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Treatment of Hemorrhagic Cystitis

Brian, Nelson & Mrinal, 2021

Treatment depends on the severity of hemorrhagic cystitis including:

Saline bladder irrigation
Instillation of intravesical agents
Hyperbaric oxygen (HBO) therapy
Urinary diversion
Iliac artery angioembolization, and
Bladder removal (cystectomy)

Patients who are actively bleeding, need to have platelet counts maintained at >50,000/microL
Address any medications that might be associated with an increased risk of bleeding)

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Mild hematuria (CTCAE grade 1 to 2)
Suprahydration
Antispasmodics
Moderate hematuria (CTCAE grade 2 to 3)
Continuous bladder irrigation
Cystoscopy with fulguration and/or clot extraction
Intravesical instillation of astringents (alum, silver nitrate, aminocaproic acid) or oral aminocaproic acid
Systemic pentosan polysulfate sodium
Hyperbaric oxygen, where available (mainly for radiation-induced hemorrhagic cystitis)
Severe hematuria (CTCAE grade 4)
Transfusion, clot extraction
In addition to the intravesical therapies described above, may need urinary diversion, intravesical formalin, iliac artery angioembolization, and/or cystectomy

Contact info: info@nursesinternational.org

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Nurse’s Role in Hemorrhagic Cystitis (HC)

NSW, 2020

Recognise and report the signs and symptoms of hemorrhagic cystitis including:

Blood in their urine
Frequency and urgency of urination
Painful urination
Vague abdominal pain
Frequently waking up at night to urinate

When HC is suspected, nurses should ask about:

Any prior urologic diagnoses or surgeries
Chemotherapy and radiation therapy [RT] treatments.

Contact info: info@nursesinternational.org

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Nurse’s Role in Hemorrhagic Cystitis (HC)

NSW, 2020

Ensure the patient is educated to:

Stay well hydrated throughout treatment.
Avoid consuming bladder irritants such as alcohol and caffeine.
Void regularly.
Take oral cyclophosphamide in the morning (if prescribed).
Take oral mesna on time as prescribed .

Contact info: info@nursesinternational.org

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References:

Brian, J. L., Nelson, J. C., & Mrinal, M. G. (2021). Hemorrhagic cystitis in cancer patients. In Savarese, D.M.F. (Eds). UpToDate. Retrieved from https://www.uptodate.com/contents/chemotherapy-and-radiation-related-hemorrhagic-cystitis-in-cancer-patients

Haldar, S., Dru, C., & Bhowmick, N. A. (2014). Mechanisms of hemorrhagic cystitis. American Journal of Clinical and Experimental Urology, 2(3), 199–208.

Contact info: info@nursesinternational.org

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References:

Manikandan, R., Kumar, S., & Dorairajan, L. N. (2010). Hemorrhagic cystitis: A challenge to the urologist. Indian Journal of Urology : IJU : Journal of the Urological Society of India, 26(2), 159–166. https://doi.org/10.4103/0970-1591.65380

NSW Government (2020.) Clinical resources: Hemorrhagic Cystitis. Retrieved from https://www.eviq.org.au/clinical-resources/side-effect-and-toxicity-management/genitourinary/1297-haemorrhagic-cystitis

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