For the IC/BPS patient, chemo induced cystitis is a real concern.

Joy*, a 73 year old woman, contacted our office in a dire situation. Three months after her diagnosis of IC/BPS, she received a second diagnosis of breast cancer (Stage 2B), underwent a mastectomy and began chemotherapy treatment. Of course, she was very concerned about how her bladder would react and told the oncologist that she had “interstitial cystitis.” Her oncologist assured her that she would not react strongly. He was wrong.  Her chemotherapy resulted in bladder pain so severe that she was confined to a wheel chair, unable to walk and struggling with long, labor like spasms in her bladder and pelvic floor. Numerous IC/BPS patients have shared that they experienced mild to moderate reactions to chemotherapy but hers was, by far, the most severe.

Chemo cystitis is real and treatable

Chemo induced bladder damage is a well known side effect to chemotherapy. It occurs after certain chemotherapy medications (cyclophosphamide, ifosfamide, busulfan, doxorubicin, dacarbazine, fludarabine, and cabazitaxel) are broken down into substances that collect in urine and then irritate the bladder lining.(1) Patients can develop urinary symptoms (burning during urination, pain, intense urgency, frequency, fever & chills). Severe reactions can cause bleeding from the bladder wall (aka hemorrhagic cystitis).  Her oncologist eventually added the medication MESNA (uromitexan), a medication that can reduce the risk of bladder irritation, but it was perhaps too late. Joy experienced no relief.

Why was her reaction to chemotherapy so severe?

The missing piece of Joy’s puzzle occurred during her diagnosis for IC/BPS. During a hydrodistention, her urologist found multiple Hunner’s lesions (wounds on her bladder wall) but failed to provide any treatment for them. The AUA Guidelines for IC/BPS recommend that lesions be treated immediately when found, with cauterization (laser, fulguration) and/or steroid injection.  Because this did not occur, the toxic bi-products of the chemotherapy were able to penetrate deeply into her bladder wall.

Treatment Options

We polled various IC specialists to ask if anything could be done to reduce Joy’s bladder pain. Treating the lesions was their first priority. Dr. Robert Evans (Wake Forest University) offered “First I would go in and laser those lesions which will help her right away.” Dr. Ken Peters (Beaumont Hospital) concurred “I would cauterize the lesions to seal them and destroy the nerve endings.”

Dr. Chris Payne (now retired) also agreed saying that if he saw lesions he would cauterize them and possibly delay chemo 30 days to allow the bladder to heal. Given that chemotherapy had already started, however, he said “At this point, a steroid injection is probably the most reasonable course.”

To address her severe pain, Dr. Evans suggested rescue (heparin/lidocaine) instillations twice a day at home, as well as B&O suppositories. He doubted that gabapentin, the medication which the oncologist prescribed to Joy, would be helpful.

Dr. Robert Moldwin emphasized that “very aggressive hydration is important.” The American Cancer Society recommends that chemo patients “drink about 1 quart of water during each 8-hour period unless you’ve been told to limit the amount you drink.” And, of course, the consideration of other chemotherapeutic agents might be necessary as well.

Tips To Protect Your Bladder From Chemotherapy If You Also Have IC/BPS

Today, we received yet another call from an IC/BPS patient newly diagnosed with cancer who wanted to protect her bladder as much as possible from the caustic effects of chemotherapy. We so understand the stress and anxiety not only for what could be a terminal diagnosis but also a credible worry about bladder pain. Here are some suggestions that may help:

#1 – Inform your oncologist that you have interstitial cystitis and bring them educational materials about IC/BPS, such as the ICN Fact Sheets and/or the newly revised AUA Guidelines for IC/BPS.
#2 – If you have Hunner’s lesions, talk with your urologist about having them treated before the onset of chemotherapy.
#3 – Ask your oncologist about what medications you can use during chemotherapy to reduce bladder irritation (i.e. Mesna)
#4 – Ask your urologist about any other bladder medications that you can use during chemotherapy to minimize bladder irritation (i.e. bladder coatings, rescue instillations, etc.)
#5 – Drink plenty of water
#6 – Elimination foods high in acid and/or alcohol (aka the IC diet) to avoid irritating your bladder more.
#7 – If you are struggling with pain, ask the oncologist or your urologist for pain care.
#8 – If you see bloody urine, have pain in your lower back, can’t urinate and/or have a fever over 100.5 or shaking a chills, call your cancer team immediately.

References

  1. Linder, et al. Chemotherapy and radiation-related hemorrhagic cystitis in cancer patients. UpToDate. December 22. Accessed January 18, 2023

Suggested Resources

  • American Cancer Societywww. cancer.org – The lead non-profit for cancer in the United states.
  • CancerCarewww.cancercare.org – Provides free information, counseling and support services to anyone affected by cancer
  • National Cancer Institutewww.cancer.gov – Provides accurate, up-to-date information about cancer to patients, their families, health professionals and the general public. (also available in spanish)

Updated: January 18, 2023 – jho