Radiation Induced Cystitis and Proctitis - Prediction, Assessment and Management

  • Published : 2015.09.02


Cystitis and proctitis are defined as inflammation of bladder and rectum respectively. Haemorrhagic cystitis is the most severe clinical manifestation of radiation and chemical cystitis. Radiation proctitis and cystitis are major complications following radiotherapy. Prevention of radiation-induced haemorrhagic cystitis has been investigated using various oral agents with minimal benefit. Bladder irrigation remains the most frequently adopted modality followed by intra-vesical instillation of alum or formalin. In intractable cases, surgical intervention is required in the form of diversion ureterostomy or cystectomy. Proctitis is more common in even low dose ranges but is self-limiting and improves on treatment interruption. However, treatment of radiation proctitis is broadly non-invasive or invasive. Non-invasive treatment consists of non-steroid anti-inflammatory drugs (NSAIDs), anti-oxidants, sucralfate, short chain fatty acids and hyperbaric oxygen. Invasive treatment consists of ablative procedures like formalin application, endoscopic YAG laser coagulation or argon plasma coagulation and surgery as a last resort.


  1. Ajith Kumar S, Prasanth P, Tripathi K, et al (2011). Hyperbaric oxygen-A new horizon in treating cyclophosphamideinduced hemorrhagic cystitis. Indian J Urol, 27, 272-3.
  2. Banerji JS, Devasia A, Kekre NS, et al (2014). Early urinary diversion with ileal conduit and vesicovaginostomy in the treatment of radiation cystitisdue to carcinoma cervix: a study from a tertiary care hospital in South India. ANZ J Surg, [Epub ahead of print].
  3. Bevers RF, Bakker DJ, Kurth KH (1995). Hyperbaric oxygen treatment for haemorrhagic radiation cystitis. Lancet, 346, 803-5
  4. Brown RB (1969). A method of management of inoperable carcinoma of the bladder. Med J Aust, 1, 23-4
  5. Carmignani G, Belgrano E, Puppo P, et al (1980). Transcatheter embilization of the hypogastric arteries in cases of bladder hemorrhage from advanced pelvic cancers: follow up in 9 cases. J Urol, 124, 196-200.
  6. Choong SK, Walkden M, Kirby R (2000). The management of intractable haematuria. BJU Int, 86, 951-9.
  7. Cotti G, Seid V, Araujo S, et al (2003). Conservative therapies for hemorrhagic radiation proctitis: a review. Rev Hosp Clin Fac Med Sao Paulo, 58, 284-92.
  8. Dellis A, Deliveliotis C, Kalentzos V, et al (2014). Is there a role for hyberbaric oxygen as primary treatment for grade IV radiation-induced haemorrhagic cystitis? A prospective pilot-feasibility study and review of literature. Int Braz J Urol, 40, 296-305.
  9. Denton AS, Andreyev HJ, Forbes A, et al (2002). Systematic review for non-surgical interventions for the management of late radiation proctitis. Br J Cancer, 87, 134-43.
  10. Denton A, Forbes A, Andreyev J, et al (2002). Non-surgical interventions for late radiation proctitis in patients who have received radical radiotherapy to the pelvis. Cochrane Database Syst Rev, 1, 3455.
  11. Fair WR (1974). Formalin in the treatment of massive bladder haemorrhage. Techniques, results, and complications. Urology, 3, 573-6.
  12. Godec CJ, Gleich P (1983). Intractable hematuria and formalin. J Urol, 130, 688-91.
  13. Goel AK, Rao MS, Bhagwat AG, et al (1985). Intra-vesical irrigation with alum for the control of massive bladder haemorrhage. J Urol, 133, 956-7.
  14. Haas EM, Bailey HR, Farragher I (2007). Application of 10 percent formalin for the treatment of radiation-induced haemorrhagic proctitis. Dis Colon Rectum, 50, 213-7.
  15. Haldar S, Dru C, Bhowmick NA (2014). Mechanisms of haemorrhagic cystitis. Am J Clin Exp Urol, 2, 199-208.
  16. Herrmann T, Knorr A, Dorner K (1987). The RTOG/EORTC classification criteria for early and late radiation reactions. Radiobiol Radiother, 28, 519-28.
  17. Hoggan BL, Cameron AL (2014). Systematic review of hyperbaric oxygen therapy for the treatment of nonneurological soft tissueradiation-related injuries. Support Care Cancer, 22, 1715-26.
  18. Hortelano E, Gomez-Iturriaga A, Ortiz-de-Zarate R, et al (2014). Is argon plasma coagulation an effective and safe treatment option for patients with chronic radiation proctitis after high doses of radiotherapy? Rev Esp Enferm Dig, 106, 165-70.
  19. Jao SW, Beart RW Jr, Gunderson LL (1986). Surgical treatment of radiation injuries of the colon and rectum. Am J Surg, 151, 272-7.
  20. Kapp KS, Stuecklschweiger GF, Kapp DS, et al (1997). Carcinoma of the cervix: analysis of complications after primary external beam radiation and Ir-192 HDR brachytherapy. Radiother Oncol, 42, 143-53.
  21. Kaushik D, Teply BA, Hemstreet GP 3rd (2012). Novel treatment strategy for refractory hemorrhagic cystitis following radiation treatment of genitourinary cancer: Use of 980-nm diode laser. Lasers Med Sci, 27, 1099-102.
  22. Kavoussi LR, Gelstein LD, Andriole GL (1986). Encephalopathy and an elevated serum aluminum level in a patient receiving intravesical alum irrigation for severe urinary hemorrhage. J Urol, 136, 665-7.
  23. Kennedy C, Snell ME, Witherow RO (1984). Use of alum to control intractable vesical haemorrhage. Br J Urol, 56, 673-5.
  24. Kim HJ, Kim S, Ha SW et al (2008). Are doses to ICRU reference points valuable for predicting late rectal and bladder morbidity after definitive radiotherapy in uterine cervix cancer? Tumori, 94, 327-32.
  25. Kumar S, Rosen P, Grabstald H (1975). Intra-vesical formalin for the control of intractable bladder hemorrhage secondary to cystitis or cancer. J Urol, 114, 540-3.
  26. Maier U, Ehrenbock PM, Hofbauer J (1997). Late urological complications and malignancies after curative radiotherapy for gynecological carcinomas: a retrospective analysis of 10,709 patients. J Urol, 158, 814-7.
  27. McGuire EJ, Weiss RM, Schiff M (1974). Hemorrhagic radiation cystitis. Treatment Urology, 3, 204-8.
  28. Montana GS, Fowler WC (1989). Carcinoma of the cervix: analysis of bladder and rectal radiation dose and complications. Int J Radiat Oncol Biol Phys, 16, 95-100.
  29. Oliai C, Fisher B, Jani A, et al (2012). Hyperbaric oxygen therapy for radiation-induced cystitis and proctitis. Int J Radiat Oncol Biol Phys, 84, 733-40.
  30. Olliff S, Thomas S, Karani J (1990). Superselective embolization using a coaxial catheter technique. Br J Radiol, 63, 197-201.
  31. Oscarsson N, Arnell P, Lodding P, et al (2013). Hyperbaric oxygen treatment in radiation-induced cystitis and proctitis: a prospective cohort study on patient-perceived quality of recovery. Int J Radiat Oncol Biol Phys, 87, 670-5.
  32. Ostroff EB, Chenault OW (1982). Alum irrigation for the control of massive bladder hemorrhage. J Urol, 128, 929-30.
  33. Singh I, Laungani GB (1992). Intravesical epsilon aminocaproic acid in management of intractable bladder hemorrhage. Urology, 40, 227-9.
  34. Tagkalidis PP, Tjandra JJ (2001). Chronic radiation proctitis. ANZ J Surg, 71, 230-7.
  35. Talab SS, McDougal WS, Wu CL, et al (2014). Mucosa-sparing, KTP laser coagulation of submucosal telangiectatic vessels in patients with radiation-induced cystitis: a novel approach. Urology, 84, 478-83.
  36. Willett CG, Ooi CJ, Zietman AL, et al (2000). Acute and late toxicity of patients with inflammatory bowel disease undergoing irradiation for abdominal and pelvic neoplasms. Int J Radiat Oncol Biol Phys, 46, 995-8.
  37. Yang L, Lv Y (2012). Possible risk factors associated with radiation proctitis or radiation cystitis in patients with cervical carcinoma after radiotherapy. Asian Pac J Cancer Prev, 13, 6251-5.
  38. Zelefsky MJ, Levin EJ, Hunt M, et al (2008).Incidence of late rectal and urinary toxicities after three-dimensional conformal radiotherapy and intensity-modulated radiotherapy for localized prostate cancer. Int J Radiat Oncol Biol Phys, 70, 1124-9.
  39. Zhu J, Xue B, Shan Y, et al (2013). Transurethral coagulation for radiation-induced hemorrhagic cystitis using Greenlight$^{TM}$ potassium-titanyl-phosphate laser. Photomed Laser Surg, 31, 78-81.

Cited by

  1. Novel and Effective Almagate Enema for Hemorrhagic Chronic Radiation Proctitis and Risk Factors for Fistula Development vol.17, pp.2, 2016,
  2. Früh- und Spättoxizitätsprofile bei Patienten mit unmittelbar postoperativer Radiotherapie vs. Salvage-Radiotherapie bei Prostatakarzinom nach Prostatektomie pp.1439-099X, 2018,