Hemorrhagic cystitis

Hemorrhagic cystitis or Haemorrhagic cystitis is diffuse inflammation of the bladder leading to dysuria, hematuria, and hemorrhage. This is seen most often in female cancer patients as a complication of therapy, however it is can also be seen in children as a result of viral infection. In the case of a viral infection, it is classified as a urinary tract infection.

Causes
Causes of hemorrhagic cystitis include chemotherapy (e.g. cyclophosphamide,methotrexate), radiation, or viral infection. Adenovirus (particularly serotypes 11 and 21 of subgroup B) is the most common cause of acute viral hemorrhagic cystitis in children, though it can result from BK virus as well.

A chemical hemorrhagic cystitis can develop when vaginal products are inadvertently placed in the urethra. Gentian violet douching to treat candidiasis has resulted in hemorrhagic cystitis when the drug was misplaced in the urethra, but this hemorrhagic cystitis resolved spontaneously with cessation of treatment. Accidental urethral placement of contraceptive suppositories has also caused hemorrhagic cystitis in several patients. The bladder irritation was thought to be caused by contact of the acidic compound nonoxynol-9 (pH, with the bladder. In the acute setting, the bladder can be copiously irrigated with alkalinized normal saline to minimize bladder irritation.  Viral causes of cystitis Although hemorrhagic cystitis associated with posttransplantation/bone marrow transplantation is not technically noninfectious, a short discussion is in order for completeness.  Patients undergoing therapy to suppress the immune system are at risk for hemorrhagic cystitis due to either the direct effects of chemotherapy or activation of dormant viruses in the kidney, ureter, or bladder.

Diagnosis
Diagnosis is made by history and examination.

In immunocompromised patients, pus is present in the urine but often no organism can be cultured. In children, polymerase chain reaction sequencing of urine can detect fragments of the infectious agent.

The procedure differs somewhat for women and men. Laboratory testing of urine samples now can be performed with dipsticks that indicate immune system responses to infection, as well as with microscopic analysis of samples. Normal human urine is sterile. The presence of bacteria or pus in the urine usually indicates infection. The presence of hematuria, or blood in the urine, may indicate acute UTIs, kidney disease, kidney stones, inflammation of the prostate (in men), endometriosis (in women), or cancer of the urinary tract. In some cases, blood in the urine results from athletic training, particularly in runners.

Symptoms
The frequency of bladder infections in humans varies significantly according to age and sex. The male/female ratio of UTIs in children younger than 12 months is four to one because of the high rate of birth defects in the urinary tract of male infants. Urinary tract infections are fairly common in young girls. In adult life, the male/female ratio of UTIs is one to 50. After age 50, however, the incidence among males increases due to prostate disorders.

Treatment
In the case of hemorrhagic cystitis from cyclophosphamide, this can be prevented through aggressive hydration and the use of mesna, which neutralizes the toxicity of acrolein, a metabolite of cyclophosphamide.

Viral hemorrhagic cystitis in children generally spontaneously resolves within a few days.

The first step in the treatment of HC should be directed toward clot evacuation. Bladder outlet obstruction from clots can lead to urosepsis, bladder rupture, and renal failure. Clot evacuation can be performed by placing a wide-lumen bladder catheter at bedside. The bladder can be irrigated with water or sodium chloride solution. The use of water is preferable because water can help with clot lysis. Care must be taken to not overdistend the bladder and cause a perforation.