Intravesical irrigation with alum for the control of massive bladder hemorrhage

Continuous vesical irrigation with 1 per cent alum solution was performed without anesthesia in 9 patients in whom massive bladder hemorrhage persisted despite evacuation of clots and normal saline irrigation for at least 24 hours. Hematuria ceased promptly in all patients, although the effect was transient in 3. No side effect was observed. Biopsy of the tumor subsequent to alum irrigation showed no alteration in the histological characteristics. Biopsy of the normal-appearing bladder mucosa also showed no evidence of epithelial damage. Ultrastructure of the tumor in 1 patient in whom transurethral resection was performed 2 weeks after alum irrigation revealed well preserved nuclear chromatin, thus, suggesting that whatever changes occur after alum irrigation are short-lived.     

Alum irrigation in massive bladder hemorrhage in severe renal failure

We report a patient with severe renal failure in whom massive bladder hemorrhage was successfully treated with alum irrigation. There was no substantial potassium or aluminum absorption with alum irrigation.     

经尿道电切加羟基喜树碱膀胱灌注治疗女性腺性膀胱炎62例分析

目的探讨腺性膀胱炎的临床特点及诊治体会。方法对62例腺性膀胱炎患者的临床资料进行回顾性分析。所有患者均行经尿道电切术,术后24h内即用羟基喜树碱（HCPT）10mg行膀胱内灌注,以后每周1次,持续8周,改为每月1次,持续10月。每3个月复查膀胱镜,持续1年。结杲所有手术均成功,手术时间平均15min,术中无严重出血和膀胱穿孔等并发症发生。随访6-24月,症状消失41例,症状好转16例,总有效率91.9％。结论经尿道电切联合术后羟基喜树碱（HCPT）膀胱内灌注是治疗腺性膀胱炎的有效方法。     

Encephalopathy and an elevated serum aluminum level in a patient receiving intravesical alum irrigation for severe urinary hemorrhage

Intravesical alum irrigation is reported to be an effective and relatively safe means of controlling severe urinary hemorrhage. We describe a patient who experienced severe encephalopathy, metabolic acidosis and unexplained coagulopathy while receiving continuous intravesical alum irrigation. The serum aluminum level was elevated. The probable role of alum absorption from the bladder as the etiology of the encephalopathy and metabolic abnormalities, as well as the pathophysiology of aluminum metabolism are discussed. Guidelines for the use of intravesical alum irrigation in patients at high risk for the development of these abnormalities are proposed.     

A case of shock following intravesical formalin instillation]

A case of shock following intravesical formalin instillation for massive bladder hemorrhage owing to post-radiation cystitis is reported. A 79-year-old woman had been treated with external irradiation for cancer of the uterine body in 1981. She was suffering from massive hematuria after hysterectomy in 1988. No hemostatic procedures were effective. Then we instilled 10% formalin into her bladder. After the instillation she entered a state of allergic shock.     

Secondary amyloidosis of the bladder: a cause of massive hematuria

Secondary amyloidosis of the bladder is a rare cause of hematuria, with only 10 previous reports. Findings and treatment in 5 patients with histologically verified bladder amyloidosis secondary to long-standing rheumatoid arthritis are presented. All patients were hospitalized for massive hematuria. One patient died before cystoscopy. Clot evacuation and fulguration through a cystoscope stopped the bleeding in 1 patient. In the other 3 patients hemostasis was achieved by cystotomy, bilateral percutaneous nephrostomy and continuous alum irrigation of the bladder, respectively.     

Treatment of hemorrhagic cystitis caused by cyclophosphamide using intravesical instillation of potassium alum. Apropos of 5 cases

Five patients with malignant hemopathies, including four treated by bone marrow transplantation, developed cyclophosphamide-induced hemorrhagic cystitis that failed to respond to the usual treatments. Each was treated by continuous irrigation of the bladder with potassium alum. Hematuria ceased in three patients followed up for 5 to 10 months. A review of the literature confirmed the 75% success rate of this treatment. No local side effects were recorded, but one patient had a single seizure.     

Intravesical epsilon aminocaproic acid in management of intractable bladder hemorrhage.

Thirty-seven patients with intractable bladder hemorrhage were treated with intravesical epsilon aminocaproic acid (EACA). Radiation cystitis and cyclophosphamide-induced cystitis were the two most common causes of intractable bladder hemorrhage. Thirty-four patients responded to treatment. No side effects were noted. Intravesical EACA appears to be a safe and effective method to control intractable bladder hemorrhage.     

Prophylactic and therapeutic carboprost tromethamine bladder irrigation in rats with cyclophosphamide-induced hemorrhagic cystitis.

Recently, prostaglandins have been shown to be effective agents for the treatment of cyclophosphamide-induced hemorrhagic cystitis. Among the prostaglandins studied is carboprost tromethamine, a PGF2a analog. To determine the effectiveness of carboprost tromethamine therapy on the urothelium, we induced hemorrhagic cystitis in 81 rats. These were divided into two treatment arms. One arm was treated prophylactically at the time of cyclophosphamide injection, and the other started treatment only after hemorrhagic cystitis was established. Animals were divided equally into groups receiving 0, 0.4, 0.8, and 1.6 mg.% carboprost tromethamine in 0.9% normal saline by continuous bladder irrigation. All bladders were examined grossly for edema and hemorrhage, then histologically for mucosal ulceration, congestion, and perivascular hemorrhage. Results from the prophylactic arm, as compared to those for controls, revealed that all groups except those treated only with 0.9% normal saline had a lower incidence of hemorrhagic cystitis (p less than 0.05). In the established hemorrhagic cystitis arm, the group treated with 1.6 mg.% carboprost tromethamine showed the best response (p less than 0.05), whereas the group treated with 0.9% normal saline showed the poorest response. This study reveals that hemorrhagic cystitis in the rat model may be prevented by prophylactic continuous bladder irrigation with carboprost tromethamine, whereas established hemorrhagic cystitis may be treated effectively with intravesical instillation of carboprost tromethamine. Although the mechanism of action of this prostaglandin on the urothelium is unknown, it appears grossly and histologically to decrease ulceration, perivascular hemorrhage, and congestion in the mucosa and submucosa.     

腺性膀胱炎的诊断与治疗(附38例报告)

目的探讨膀胱镜在腺性膀胱炎的诊断和治疗中的应用。方法 膀胱镜检查和活检，病理诊断为腺性膀胱炎38例，电切镜下行病灶电切/电灼术，术后丝裂霉素膀胱灌注化疗（每周1次，共8次，其后每月1次，共10次）。结果38例随访6-12个月，29例治愈，膀胱黏膜逐渐恢复为移行上皮覆盖；症状缓解5例；复发4例。结论膀胱镜检查对腺性膀胱炎的诊断具有重要参考价值，经尿道电切镜下病灶电切/电灼术联合术后丝裂霉素膀膛灌注化疗，对腺性膀胱炎治疗效果明显。     

Clinical study of bladder tamponade resulting from clots of blood

PURPOSE: There were many case reports about bladder tamponade resulting from clots of blood. However, there were few reports about the clinical study that result from collecting cases of bladder tamponade. Thus, we performed a retrospective study about bladder tamponade resulting from clots of blood that we had managed. MATERIAL AND METHODS: We investigated 20 patients who had bladder tamponade and were consulted at our facility between October 2002 and September 2005. We researched causes of the bleeding, characteristics of the patients, the laboratory data of coagulation system and treatments of our experience in managing patients. There were 17 males and 3 females. The average age of the patients was 74.0 years old. RESULTS: 8 cases took anticoagulant drugs, 6 cases had medical history of cerebral infarction or cardiac infarction, 4 cases took anticholinergic drugs and 9 cases had benign prostate hypertrophy or urethral stricture. Bleeding was due to bladder tumor in 9, prostate cancer in 1, radiation cystitis in 3, chronic cystitis in 1, malignant lymphoma in 1, idiopathic causes in 3 and unknown causes in 2 cases. Except 1 case, in all cases, evacuation of the clots was the first procedure followed by saline irrigation. This initial line of treatment was able to control the hemorrhage in 40% of the patients. For the remaining cases, transurethral coagulation and resection of bladder tumor were used as the second line treatment, and furthermore, radical cystectomy was performed in 1 case. Surgical treatments were required in 12 cases. Blood transfusion was required in 4 cases. CONCLUSION: According to progress aging society, the amounts of taken anticoagulant drugs and the patients who had lower urinary tract dysfunction may increase. It may be suggested that the cases of bladder tamponade resulting from clots of blood without bladder tumor or radiation cystitis tend to increase.     

Severe hemorrhagic cystitis

Hemorrhagic cystitis is bleeding which originates from the bladder. Chemotherapy and radiation account for the majority of cases, but it can also result from a variety of drugs, infections, or a primary cancer. It is a significant problem after allogeneic bone marrow transplantation, and is associated with a high mortality rate. Bladder manipulations with instillations of alum, formalin, phenol, and silver nitrate have had limited success for cystitis after bone marrow transplantation. Prostaglandin bladder instillation is a simple bedside procedure that appears promising for this group of patients. While it is not a guaranteed treatment for all patients, it offers clear advantages over the previous treatments that were available. When prostaglandin bladder instillations fail, then surgical intervention with urinary diversion is justified.     

Continuous bladder irrigation prevents hemorrhagic cystitis after allogeneic hematopoietic cell transplantation

Hemorrhagic cystitis is 1 of the most troublesome complications of hematopoietic cell transplantation conditioning regimens. We conducted a nonrandomized controlled clinical study to investigate the role of continuous bladder irrigation in addition to mesna, hydration, and alkalization in the prevention of hemorrhagic cystitis after allogeneic hematopoietic cell transplantation. A total of 80 eligible patients entered the study. From May 2006, 40 patients who underwent allogeneic hematopoietic cell transplantation received continuous bladder irrigation in addition to the common protocol. A historical control group of 40 consecutive patients with same inclusion criteria who did not receive bladder irrigation was enrolled from before May 2006. Hemorrhagic cystitis occurred in 50% of patients in the no bladder irrigation group versus 32% in bladder irrigation group (P = 0.11). The mean duration of hemorrhagic cystitis was significantly reduced in the bladder irrigation group (10 vs. 18 days; P = 0.02). Duration of hospitalization was significantly shorter in the bladder irrigation group (30.2 vs. 39.6; P < 0.001). Late-onset hemorrhagic cystitis that occurred beyond 4 weeks after allo-hemorrhagic cystitis happened more significantly in the no bladder irrigation group (P = 0.001). High-grade hemorrhagic cystitis was more frequently associated with high-grade graft-versus-host disease within 30 days after transplant (P = 0.06). In general, continuous bladder irrigation added to mesna, hydration, and alkalization regimens was well tolerated, decreased the complications of hemorrhagic cystitis, and may be useful in hematopoietic cell transplantation patients. However, more investigations with randomized controlled clinical trials with more patients are needed.     

Hemorrhagic radiation cystitis: a transurethral treatment with formalin-soaked pledgets

An 80-year-old woman presented with gross hematuria and clot retention about 20 years after postoperative radiation therapy for uterine cancer. Endoscopic evaluation revealed a hyperemic bladder mucosa and bleeding foci localized to the posterior wall. Electrocauterization and continuous bladder irrigation with normal saline failed to resolve the hemorrhage, Maalox (aluminum hydroxide/magnesium hydroxide) was instilled intravesically. The events of gross hematuria and clot retention recurred frequently, cotton pledgets soaked in 5% formalin were placed endoscopically onto the bleeding sites of the bladder posterior wall for 15 minutes with success. We consider this technique useful for intractable hemorrhage secondary to radiation cystitis.     

Cyclophosphamide-induced intractable hemorrhagic cystitis treated with hyperbaric oxygenation and intravesical sodium hyaluronate

Cyclophosphamide is a well-known cause of hemorrhagic cystitis. However, the best treatment for hemorrhagic cystitis is still unknown. Herein, we present a patient with cyclophosphamide-induced hemorrhagic cystitis. The patient had a history of myasthenia gravis and had received cyclophosphamide therapy for 14 years. He was admitted due to gross hematuria, which was initially treated by cystoscopic fulguration, followed by continuous bladder irrigation. Due to refractory hemorrhaging, fulguration was repeated and percutaneous suprapubic cystostomy was performed. The bladder hemorrhage eventually subsided after hyperbaric oxygen therapy and intravesical sodium hyaluronate instillation. The combination of hyperbaric oxygen therapy and intravesical sodium hyaluronate instillation may be useful in severe hemorrhagic cystitis caused by cyclophosphamide.     

Endoscopic Topical Placement of Formalin Soaked Pledgets to Control Localized Hemorrhage Due to Radiation Cystitis

Purpose

A useful technique for treating localized bladder hemorrhage secondary to radiation cystitis is described.

Materials and Methods

Cotton pledgets soaked in 5% formalin are placed endoscopically onto bleeding foci of the bladder for 15 minutes and then removed.

Results

There was immediate cessation of prolonged bleeding refractory to intravesical saline, alum, prostaglandin E1 and estrogen. No subsequent bleeding was noted during 16 months of followup.

Conclusions

Topical application of formalin soaked pledgets is an effective method of controlling localized bleeding secondary to radiation cystitis.     

经尿道电切加膀胱化疗药物灌注治疗腺性膀胱炎

目的 提高腺性膀胱炎诊疗水平。方法 腺性膀胱炎患者32例，膀胱镜检膀胱黏膜表现为滤泡样或绒毛样、乳头样、慢性炎症改变。经尿道电切术加丝裂霉素或吡柔比星膀胱灌注，规律治疗1年，方案为每周1次共8次，其后每月1次共10次，定期做膀胱镜检查。结果 随访7-36个月，平均18个月。28例痊愈，4例复发，无恶变病例。结论经尿道电切，术后丝裂霉素或吡柔比星膀胱灌注治疗腺性膀胱炎，疗效满意、毒副作用低，是治疗腺性膀胱炎的较好方法。     

Therapeutic options for intractable hematuria in advanced bladder cancer

Intractable hematuria is a common and severe complication in patients with inoperable bladder carcinoma. The aim was to provide an overview of therapeutic options for such cases, and analyze their effectiveness and risk profile, so a systematic literature search of peer‐reviewed papers published up to September 2012 was carried out. Various options are available to treat hematuria in patients with inoperable bladder cancer; these include orally administered epsilon‐aminocaproic acid, intravesical formalin, alum or prostaglandin irrigation, hydrostatic pressure, urinary diversion, radiotherapy, embolization and intraarterial mitoxantrone perfusion. These treatment options are associated with different prospects of success, risks and side‐effects. Well‐designed and large studies comparing options are completely lacking. Despite various treatment options, management of intractable hematuria in patients with inoperable bladder cancer remains a challenge, and most of the reported methods should be seen as experimental. Interventional radiology and alum instillation seem to be suitable alternative options for patients who, after critical consideration, cannot be treated by irrigation, transurethral resection or palliative cystectomy.     

Intravesical formalin instillation in the treatment of massive haematuria

16 patients with massive haematuria due to bladder cancer or cytostatic or radiation cystitis have been treated with intravesical instillation of 4% formalin solution. The method proved to be effective in the control of bleeding in 15 cases, but produced complications two of which were severe. This mode of treatment should thus be limited to debilatated patients in whom other conservative methods fail to control the bleeding. Complications and mode of action of formalin instillation are discussed.     

Formalin treatment of refractory hemorrhagic cystitis in systemic lupus erythematosus

Hemorrhagic cystitis is a potentially life-threatening complication in systemic lupus erythematosus (SLE). No safe, effective and conservative treatment exists for patients who fail to respond to standard therapy. We report a 17-year-old girl with SLE who suffered from severe hemorrhagic cystitis. Initially, she received frequent red blood cell and platelet transfusions, continuous bladder irrigation, and blood clots were evacuated. Numerous kinds of treatment were tried, including electrocoagulation of bleeding foci, prostaglandin E₁ bladder instillation, and hyperbaric oxygen. However, she remained severely anemic and thrombocytopenic necessitating daily transfusions of blood products. After intravesical formalin instillation was performed twice, the hematuria ceased completely. Received February 11, 1998; received in revised form June 1, 1998; accepted June 2, 1998