The patient’s symptoms are consistent with hemorrhagic cystitis in the setting of recent initiation of chemotherapy. Hemorrhagic cystitis is a common complication of cyclophosphamide, which is an alkylating agent.
Hemorrhagic cystitis is a serious complication of chemotherapy (most commonly cyclophosphamide), radiation, and infection (both bacterial and viral). It is characterized by diffuse bladder mucosal inflammation with varying degrees of hemorrhage, sometimes requiring transfusion. Symptoms include urgency, frequency, dysuria, abdominal discomfort, hematuria, and clots passing in the urine. Clots may obstruct urine outflow and result in an inability to empty the bladder. Diagnostic work-up usually includes urinalysis, urine bacterial and viral cultures, cytology, ultrasonography, and cystoscopy. Patients undergoing radiation and/or chemotherapy typically undergo a prophylactic regimen including bladder irrigation, suprahydration, and mesna. Treatment options include hyperbaric oxygen, intravesical irrigation with alum, prostaglandins, and surgical intervention or vascular embolization.
Berkey discusses the management of common adverse effects of radiation therapy, of which cystitis is included. Radiation therapy for prostate, colorectal, bladder, and pelvic tumors most commonly affects the bladder mucosa. Intravenous hydration, mesna, and amifostine have demonstrated efficacy in treating hemorrhagic cystitis in patients receiving chemotherapy.
Korkmaz et al. compare the effectiveness of mesna in protecting against hemorrhagic cystitis following cyclophosphamide use to adjuvant hyperbaric oxygen therapy with mesna in a guinea pig model. They report that the combination of hyperbaric oxygen and mesna promoted bladder healing superior to either treatment individually.
Illustration A shows hemorrhagic cystitis on cystoscopy due to radiation treatment. Illustration B displays a diagnosis algorithm for hemorrhagic cystitis.
Answer 2: Intercalating agents such as doxorubicin may cause cardiotoxicity.
Answer 3: Reverse transcriptase inhibitors are used to treat HIV. An example of one of these is Didanosine, which can cause pancreatitis and peripheral neuropathy as adverse effects. No reverse transcriptase inhibitors are known to cause hemorrhagic cystitis.
Answer 4: Microtubule inhibitors such as vincristine cause neurotoxicity while vinblastine causes bone marrow suppression.
Answer 5: Folic acid analogues such as methotrexate can cause myelosuppression and fatty change in liver.
Berkey FJ. Managing the Adverse Effects of Radiation Therapy. Am Fam Physician. 2010 Aug 15;82(4):381-388.
PMID:20704169 (Link to Abstract)
Korkmaz A, Oter S, Deveci S, Goksoy C, Bilgic H. Prevention of further cyclophosphamide induced hemorrhagic cystitis by hyperbaric oxygen and mesna in guinea pigs. J Urol. 2001 Sep;166(3):1119-23.
PMID:11490309 (Link to Abstract)
USMLE Step 2 CK Qbook 4th ed. Daugherty, Stephen R. New York: Kaplan Publishing, 2008.