Clinicians struggle to treat a refractory case of hemorrhagic cystitis
I encountered my most memorable patient while working as a urology nurse practitioner at a large urban hospital. The patient was 70 years old, alert and oriented and lived in a nursing home. He had a complicated medical history, which included prostate cancer treated with radiation 15 years prior, as well as diabetes, hypertension and coronary artery disease.
The patient had a surgical history of a below-the-knee amputation and an extensive pelvic surgery, which he did not remember details about. Attempts to obtain old medical records were unsuccessful.
The patient presented with a two-day history of gross hematuria and a low-grade fever. Urine cultures and blood cultures along with routine labs were obtained along with placement and irrigation of an indwelling Foley catheter. Cultures did not reveal any infection, yet the hematuria persisted.
The patient was placed on continuous bladder irrigation with a three-way catheter. He went into clot retention several times and was ultimately taken for cystoscopy, fulguration of bleeders and biopsy. He continued to bleed.
The biopsy revealed hemorrhagic cystitis as a result of his prior radiation therapy for prostate cancer. His prostate-specific antigen levels were normal, and there was no evidence of a return or extension of the prostate cancer.
We tried multiple medical and surgical therapies using a multidisciplinary approach. Additives such as alum and aminocaproic acid were added to his continuous irrigation bags with no results. We initiated hyperbaric oxygen treatment. A urologist performed formalin instillation during cystoscopy. This initially cleared the patient's urine, but the hematuria returned several days later.
The pharmacist researched and suggested conjugated estrogen therapy, which initially worked. The patient was discharged on oral estrogen and maintained at the nursing home. He returned several weeks later with gross hematuria.
This refractory and challenging case of hemorrhagic cystitis required the assistance of an interventional radiologist who placed bilateral nephrostomy tubes to divert the urine away from the bladder. He also performed selective arterial embolization. Ultimately, this treatment was successful.
The patient was a charming man. He had a great sense of humor, a tremendous will to live, and he loved to eat. He always had a little stash of snacks in his tabletop drawer and ordering food for the next day's meal was the highlight of his day. I spent countless hours with him over the course of multiple admissions during a several month time period. I irrigated clots out of his bladder, talked with him about the next steps to stop the bleeding and tried to allay his anxiety.
Through all of this, I always left the room with a smile on my face because of his great attitude, despite the incredible suffering he dealing with. He was resilient, brave, funny and strong. I will remember him always for this and for the intense challenge of treating him!