What is Hemorrhagic Cystitis?

Certain agents used in chemotherapy such as cyclophosphamide may result in high concentrations of byproducts in the urine, potentially causing hemorrhagic cystitis.

Hemorrhagic cystitis is an inflammation of the bladder that leads to pain and hematuria, or blood in the urine. There are a number of reasons why a person with a leukemia or lymphoma may be at risk for developing hemorrhagic cystitis.

What Causes Hemorrhagic Cystitis?

The most common class of chemotherapy agents causing hemorrhagic cystitis are the alkylating agents, cyclophosphamide and ifosphamide.

Unfortunately, these are drugs that are commonly used in the treatment of blood and marrow cancers, such as leukemia and lymphoma. Other less common agents include temozolamide, bleomycin and doxorubicin.

When the body breaks down cyclophosphamide or ifosphamide, a byproduct called acrolein is produced, which is filtered out of the blood by the kidney and becomes highly concentrated in the urine within the bladder. This irritates the lining of the bladder, leading to the discomfort of cystitis as well as ulcers that can cause serious bleeding. The incidence of hemorrhagic cystitis is about six percent in people undergoing bone marrow transplantation and receiving high-dose cyclophosphamide. Ifosphamide has been associated with a higher incidence of hemorrhagic cystitis in some studies.

Certain viruses, such as adenovirus, BK virus, and JC virus, can also cause hemorrhagic cystitis. People with lowered immune systems are at higher risk of these conditions, particularly those who are recovering from bone marrow or stem cell transplant.

Finally, irritation of the bladder from exposure to radiation therapy is also a cause of hemorrhagic cystitis in cancer patients.

Symptoms of Hemorrhagic Cystitis

If you have ever experienced the discomfort of a serious urinary tract infection, you have an idea of the nature of some of the symptoms of hemorrhagic cystitis.

These symptoms include:

  • Hematuria (blood in the urine)
  • Abdominal discomfort
  • Pain or burning when passing your urine
  • Feeling like you are unable to empty your bladder
  • Loss of bladder control (incontinence)
  • Frequent or urgent need to empty your bladder
  • Getting up several times a night to pass your urine

Risk Factors for Hemorrhagic Cystitis

There are a few reasons why people with leukemia or lymphoma might be more prone to getting hemorrhagic cystitis. These risk factors include:

  • Receiving cyclophosphamide or ifosphamide as part of your chemotherapy regimen
  • Having radiation therapy to the pelvic area
  • Lowered immune system making you more susceptible to frequent urinary tract infections or viruses
  • Frequent use of antibiotics
  • Low platelet counts (thrombocytopenia)

Treatment of Hemorrhagic Cystitis

Hemorrhagic cystitis can lead to severe blood loss and is taken very seriously. Open ulcers in the bladder can provide a portal for bacteria to pass into your bloodstream. It may also lead to permanent scarring of the lining of the bladder, which could cause blockage of the urinary tract or bladder constriction.

Therefore, prompt treatment of this condition is necessary.

Treatment might include:

  • Symptom relief and pain control
  • Platelet transfusions to help control bleeding
  • Blood transfusions if the bleeding has caused anemia
  • Antibiotic or antiviral therapy if the cause of the cystitis is infectious in nature
  • Irrigation of the bladder with a saline solution to prevent clots, or medications to control bleeding

How Can Hemorrhagic Cystitis Be Prevented?

The best way to treat hemorrhagic cystitis is to prevent it from happening in the first place. If you are identified as being high risk for developing this complication, your healthcare team will likely take a few preventative measures. Most of these interventions work by decreasing the amount of time that the lining of your bladder is exposed to acrolein or other irritants. They may:

  • Administer a medication called MESNA (2-Mercaptoethanesulfonate sodium), which helps protect your bladder from the effects of acrolein. This medication is given intravenously, either in a separate bag or added to the actual bag of chemotherapy
  • Give lots of intravenous fluids to help the chemo pass through your bladder more quickly
  • Try to give your chemotherapy early in the day so you have an opportunity to clear it from your bladder before resting for the night
  • Encourage you to try to urinate at least every hour
  • Administer diuretics, which help keep urine flowing to clear the chemo from your bladder
  • Insert a urinary catheter so the chemo is continuously removed from your bladder before it has the opportunity to cause ulceration

When Should You Be Concerned?

You should get in touch with your healthcare team if:

  • You have blood in your urine
  • You develop a fever or chills
  • You have urinary symptoms that are making you uncomfortable
  • You have any questions about symptoms you are experiencing

Bottom Line

Hemorrhagic cystitis is a condition that can cause severe bleeding and permanent bladder damage if not treated. There are many factors that place leukemia and lymphoma patients at an increased risk of developing hemorrhagic cystitis. Fortunately, there are ways to help prevent this condition from occurring, as well as ways to treat it if it does occur.

As with any troublesome symptom, you should speak to your healthcare provider if you have any concerns about how you are passing your urine.

Updated March 2016, TI.


Camp- Sorrel, D. Chemotherapy: Toxicity Management. In Yarbro, C., Frogge, M., Goodman, M., Groenwald, S.(eds.) (2000) Cancer Nursing: Principles and Practice. Jones and Bartlett: Sudbury, MA. (pp.444-486.)

Oncology: An Evidence-Based Approach; Alfred E. Chang, Patricia A Ganz, Daniel F. Hayes, Timothy Kinsella, Harvey I. Pass, Joan H. Schiller, Richard M. Stone, Victor Strecher. Springer Science & Business Media, Dec 8, 2007.

MESNA Package Insert. https://www.accessdata.fda.gov/drugsatfda_docs/nda/2002/20-855_Mesnex_Prntlbl.pdf. Accessed March 2016.

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