Intravesical hyaluronic acid – An effective option in the treatment of hemorrhagic radiocystitis

Department of Urology at Bogomolets National Medical University, Head of Department of Inflammatory Diseases of the Government Institution “Institute of Urology of the National Academy of Medical Sciences of Ukraine”,
Department of Urology of the Municipal Enterprise “Cherkasy Regional Hospital of Cherkasy Regional Council“


  Hemorrhagic cystitis – an inflammatory disease of the bladder with a complex etiology. The frequency of this pathology has increased substantially due to the increase in the number of patients undergoing radiation therapy for malignant neoplasms of pelvic organs. The development of a rational treatment for hemorrhagic cystitis is a difficult problem. Given the pathogenetic basis of this disease, it is assumed that, the optimal method of treatment should be aimed at the regeneration of the glycosaminoglycan mucosal layer of the
bladder.

This article presents the results of a study of the effectiveness of intravesical instillations of hyaluronic acid in the treatment of hemorrhagic cystitis.

Keywords: hemorrhagic cystitis, hyaluronic acid, radiotherapy.

Hemorrhagic cystitis (HC) is a diffuse inflammatory disease of the bladder of infectious and non-infectious etiology, which is characterized by mucosal bleeding. This pathology is often a serious complication of the use of cytostatics or radiation therapy concerning malignant neoplasms of the pelvic organs, especially in combination with the transplantation of hematopoietic stem cells. A characteristic symptom that distinguishes HC from other forms of bladder inflammations is the present of blood in urine.

Moreover, hematuria varies from microscopic to pronounced, with the formation of clots, blocking the urinary tract. Obstruction of the urinary tract can lead to the development of hydronephrosis and acute renal failure in both chronic and recurrent course of the process. In addition, the clinical picture of HC is characterized by frequent urination, usually of imperative (urgent) character, and lower abdominal pain, extending to the whole pelvic area. The act of urination is also accompanied by painful sensations, including burning and cutting in the urethra. Over time, the capacity of the bladder decreases in many patients due to fibrous changes in its wall. Chronic blood loss leads to an anaemic state in patients, which is manifested by weakness, increased fatigue, pallor and at a severe degree – the appearance of shortness of breath, tachycardia, syncope.

Currently, it has been proven that the main link in the pathogenesis of chronic inflammation of the urinary bladder (hemorrhagic, interstitial cystitis/painful bladder syndrome, recurrent infections) is due to damage of the glycosaminoglycan layer. As a result of this disorder, epithelial cells are exposed to toxic components of urine, which exacerbate the destructive process in the mucosa.

In the search for effective remedies for the treatment of chronic inflammation of the bladder, most specialists have come to the conclusion that the intravesical instillations of medications contributing to the restoration of the inner layer of the mucous membrane are the optimal method. Based on the analysis of information on the effectiveness of various methods for the prevention and treatment of interstitial cystitis or HC, many scientists concluded that intravesical administration of hyaluronic acid is the most reasonable method at the standpoint of evidence-based medicine [1-3].

Hyaluronic acid is the most important component of the intercellular matrix, an essential component of the glycosaminoglycan layer, which as a protective barrier of the urothelium, helps prevent inflammatory processes of the bladder. Intravesical instillations of hyaluronic acid are recommended by the European Association of Urologists for the treatment of painful bladder syndrome (grade B recommendation). Herewith, it has been noted that the effectiveness of such an administration persists for a long period (level of evidence 2b) [4].

The effect of hyaluronic acid in HC therapy has been demonstrated in a number of studies. Thus, M. Miodosky et al. (2007) demonstrated that hyaluronic acid has a rapid positive effect in eliminating hematuria, pain syndrome and decreasing the frequency of urinations [5]. M. Sommariva et al. (2010) showed that intravesical administration of the drug causes a significant reduction of the symptoms of cystitis induced by chemo- and radiotherapy [2]. Based on the results of these and other studies, experts of the British Association of Urological Surgeons (BAUS) recommend the intravesical administration of hyaluronic acid for the prevention and treatment of HC in cancer patients [6].

The purpose of our study was to evaluate the effectiveness of intravesical administration of hyaluronic acid to relief symptoms of HC induced by radiotherapy.