Radiation-induced cystitis

Radiation therapy, also known as radiotherapy, is a type of cancer treatment. It involves high doses of radiation (radioactive energy) which destroys cancer cells and shrinks tumours. Radiotherapy can be given from outside the body (also called ‘external beam’) or inside the body via a radiation implant (also called ‘brachytherapy’).

Radiotherapy doesn’t work straightaway or destroy cancer after a single treatment. It involves days or weeks of treatment for the radiation to build up and reach an effective level. However, the benefits of radiotherapy last even after treatment has finished and cancer cells will continue to die over the following weeks and months once treatment is over.

Unfortunately, radiotherapy can also harm healthy, non-cancerous cells in the nearby tissues in the body.

After radiotherapy, some people will develop ‘radiation-induced cystitis’. This may happen if they have had radiotherapy to an area near to the bladder, such as the pelvis or abdomen.

Radiation-induced cystitis means inflammation or damage in the bladder or the urethra (the wee tube leading out of body) caused by, and occurring after, radiotherapy.

Another side-effect of radiotherapy can be bleeding from the bladder. This is known as radiation-induced haemorrhagic cystitis. This can be caused by radiotherapy but also by chemotherapy.

Radiation cystitis doesn’t affect everybody who has had radiation therapy to their lower body in the same way. Some people may never develop radiation cystitis at all.

Other people do but develop it at different timepoints:

Acute radiation cystitis means that the cystitis symptoms occur immediately, either during therapy or shortly after. This type of radiation cystitis generally lasts for a relatively short period of time, for example, for 3 to 6 months after radiotherapy treatment and then goes away.

Delayed (or ‘late phase’) radiation cystitis is where the radiation cystitis symptoms appear after a period of time following radiotherapy completion, for example, the symptoms may start 6 months after the last treatment. It is possible for radiation cystitis symptoms to start years after radiotherapy completion.
Radiation cystitis that occurs in a delayed manner can take a chronic (long-lasting) form, causing symptoms over many years.

If radiation comes into contact with the bladder, for example, following radiotherapy to treat a cancer in a nearby part of the body, it can affect the bladder’s normal functioning. For instance, radiation can damage the lining and wall of the bladder, causing symptoms such as:

• bladder pain
• spasms (sudden tightenings)
• urgent need to urinate
• needing to go to the toilet more often to urinate
• dysuria (a painful or burning sensation when urinating).

These symptoms can range from very mild to severe in terms of how they affect a person. Some people may experience mild discomfort in their bladder, other people may have bladder pain that requires pain relief, for example.

In severe cases, radiotherapy can cause more extensive damage to the bladder and cause:

• contracted bladder (where the bladder becomes much smaller in size and isn’t able to hold as much liquid before you need to go to the toilet)
• persistent incontinence (longer-term inability to hold in urine until you go to the toilet, or leaking urine)bladder ulcers (lesions on the wall of the bladder that can bleed)
• necrosis (where tissue/lining in the bladder dies and rots away)
• haematuria (bleeding) which can be mild or sometimes very severe

In very severe cases, if tissue between the bladder and colon dies and rots away, this can cause what is called a ‘fistula’ (an abnormal, open connection) between the colon and the bladder, which can allow faeces to incorrectly enter the bladder, causing infections and other problems.

The symptoms listed above can quite understandably have an impact on a person’s quality of life that can range from slight to severe depending on the symptom and how serious, upsetting or burdensome it is.

It is important to know that there are treatments (such as medication or surgery), therapies and products that can treat or help a person to cope with radiation cystitis.

Complications involving the bladder, and which are caused by radiation, are graded on a scale devised by an organisation called the Radiation Therapy Oncology Group (RTOG). Using the scale helps healthcare professionals to understand quickly, how severe a patient’s symptoms are and to ensure a common understanding of symptom severity.

The scale is as follows:

• Grade 1 – Any slight damage to the delicate surface of the bladder (‘epithelial atrophy’), microscopic/very small detection of blood in the urine (‘haematuria’), mild areas where clusters of small blood vessels develop (‘telangiectasia’).
• Grade 2 – Any moderately troublesome need to urinate frequently, more involved clusters of blood vessels, occasional visible blood in the urine (‘macroscopic haematuria’), occasional incontinence.
• Grade 3 – Any severe frequency and urgency urinating, severe clusters of blood vessels, persistent incontinence, smaller bladder capacity (where the bladder can hold less than 150ml of fluid), frequent blood in the urine.
• Grade 4 – Any dying or decomposing tissue in the bladder, abnormal connection between the bladder and colon (‘fistula’), haemorrhagic cystitis, small bladder capacity (where the bladder can hold less than 100ml of fluid), refractory incontinence (where medical treatments and lifestyle changes haven’t worked) requiring a catheter (to drain away urine from the bladder into a pouch) or surgical intervention.

Radiation-induced cystitis can mimic many different conditions and diseases such as urinary tract infection and stone disease.
A complete medical investigation of the urinary tract is necessary to rule out other disorders and to make an accurate diagnosis. Investigation should include the following:

• an analysis of the urine to assess for blood and pus and to measure urine culture to confirm or exclude infection;
• a urinary cytology where a small amount of urine is examined under a microscope to look for abnormalities or cancer;
• a complete blood count (blood test); and
• a cystoscopy (where a surgical tool with a camera on the end is threaded up the urethra to look inside the bladder).

Initial management includes lifestyle changes such as drinking plenty of fluids, avoiding food and drink that irritate the bladder (e.g. caffeine, alcohol, spicy foods, acid foods).

Treatment is aimed at relieving symptoms and depends on the severity and nature of these. It may include pain-killing medications (‘analgesics’), drugs to reduce inflammation (‘NSAIDs’), and drugs to treat bladder spasms (‘anticholinergics’) to relieve urgency and frequency. Oral pentosan polysulfate sodium treatment may help to repair the protective layer of mucus that lines the bladder, in milder cases of radiation-induced cystitis.

Intravesical treatment with GAG installations (drugs that replenish the bladder lining) such as the combination of hyaluronic acid and chondroitin sulfate has been shown to help relieve symptoms and may help to regenerate the bladder lining.

Bladder irrigation (sometimes called a bladder wash) may also be necessary. This involves filling the bladder with liquid medicines before draining it away.

Hyperbaric oxygen therapy is a non-invasive, experimental treatment that may help bladder inflammation in severe cases.

As a last resort in severe (‘end-stage’) radiation cystitis, surgery to divert the urine, either temporarily or permanently, may be needed, with or without removal of the bladder (‘cystectomy’).