Hemorrhagic cystitis is damage to the inner lining of your bladder and the blood vessels that supply the inside of your bladder.

Hemorrhagic means bleeding. Cystitis means inflammation of your bladder. If you have hemorrhagic cystitis (HC), you have signs and symptoms of bladder inflammation along with blood in your urine.

There are four types, or grades, of HC, depending on the amount of blood in your urine:

  • grade I is microscopic bleeding (not visible)
  • grade II is visible bleeding
  • grade III is bleeding with small clots
  • grade IV is bleeding with clots large enough to block the flow of urine and require removal

The most common causes of severe and long-lasting HC are chemotherapy and radiation therapy. Infections can also cause HC, but these causes are less severe, don’t last long, and are easier to treat.

An uncommon cause of HC is working in an industry where you’re exposed to toxins from aniline dyes or insecticides.


A common cause of HC is chemotherapy, which can include the drugs cyclophosphamide or ifosfamide. These drugs break down into the toxic substance acrolein.

Acrolein goes to the bladder and causes damage that leads to HC. It may take weeks or months after chemotherapy for symptoms to develop.

Treating bladder cancer with bacillus Calmette-Guérin (BCG) can also cause HC. BCG is a drug placed into the bladder.

Other cancer drugs, including busulfan and thiotepa, are less common causes of HC.

Radiation therapy

Radiation therapy to the pelvic area can cause HC because it damages blood vessels that supply the lining of the bladder. This leads to ulceration, scarring, and bleeding. HC can occur months or even years after radiation therapy.


Common infections that can cause HC are viruses that include adenoviruses, polyomavirus, and type 2 herpes simplex. Bacteria, fungi, and parasites are less common causes.

Most people who have HC caused by infection have a weakened immune system from cancer or treatment for cancer.

Risk factors

People who need chemotherapy or pelvic radiation therapy are at higher risk for HC. Pelvic radiation therapy treats prostate, cervix, and bladder cancers. Cyclophosphamide and ifosfamide treat a wide range of cancers that include lymphoma, breast, and testicular cancers.

The highest risk for HC is in people who need a bone marrow or stem cell transplant. These individuals may need a combination of chemotherapy and radiation therapy. This treatment can also lower your resistance to infection. All of these factors increase the risk of HC.

The primary sign of HC is blood in your urine. In stage I of HC, the bleeding is microscopic, so you won’t see it. In later stages, you may see blood-tinged urine, bloody urine, or blood clots. In stage IV, blood clots may fill your bladder and stop urine flow.

Symptoms of HC are similar to those of a urinary tract infection (UTI), but they may be more severe and long-lasting. They include:

Speak to your doctor if you experience any HC symptoms. UTIs rarely cause bloody urine.

You should contact your doctor right away if you have blood or clots in your urine. Seek emergency medical care if you’re unable to pass urine.

Your doctor may suspect HC from your signs and symptoms and if you have a history of chemotherapy or radiation therapy. To diagnose HC and rule out other causes, such as a bladder tumor or bladder stones, your doctor may:

  • order blood tests to check for infection, anemia, or a bleeding disorder
  • order urine tests to check for microscopic blood, cancer cells, or infection
  • do imaging studies of your bladder using CT, MRI, or ultrasound imaging
  • look into your bladder through a thin telescope (cystoscopy)

Treatment of HC depends on the cause and the grade. There are many treatment options, and some are still experimental.

Antibiotic, antifungal, or antiviral medications may be used to treat HC caused by an infection.

Treatment options for chemotherapy or radiation therapy-related HC include the following:

  • For early-stage HC, treatment may start with intravenous fluids to increase urine output and flush out the bladder. Medications may include pain medication and medication to relax bladder muscles.
  • If bleeding is severe or clots are blocking the bladder, treatment includes placing a tube, called a catheter, into the bladder to flush out the clots and irrigate the bladder. If bleeding continues, a surgeon may use cystoscopy to find areas of bleeding and stop the bleeding with an electric current or a laser (fulguration). Side effects of fulguration can include scarring or perforation of the bladder.
  • You may receive a blood transfusion if your bleeding is persistent and blood loss is heavy.
  • Treatment can also include placing medication into the bladder, called intravesical therapy. Sodium hyaluronidase is an intravesical therapy drug that may decrease bleeding and pain.
  • Another intravesical medication is aminocaproic acid. A side effect of this medication is the formation of blood clots that can travel through the body.
  • Intravesical astringents are medications put in the bladder that cause irritation and swelling around blood vessels to stop bleeding. These medications include silver nitrate, alum, phenol, and formalin. Side effects of astringents may include swelling of the bladder and decreased urine flow.
  • Hyperbaric oxygen (HBO) is a treatment that includes breathing 100 percent oxygen while you’re inside an oxygen chamber. This treatment increases oxygen, which may help healing and stop bleeding. You may need a daily HBO treatment for up to 40 sessions.

If other treatments aren’t working, a procedure called embolization is another option. During an embolization procedure, a doctor places a catheter into a blood vessel that leads to bleeding in the bladder. The catheter has a substance that blocks the blood vessel. You may experience pain after this procedure.

The last resort for high-grade HC is surgery to remove the bladder, called cystectomy. Side effects of cystectomy include pain, bleeding, and infection.

Your outlook depends on the stage and the cause. HC from infection has a good outlook. Many people with infectious HC respond to treatment and don’t have long-term problems.

HC from cancer treatment can have a different outlook. Symptoms may start weeks, months, or years after treatment and may be long-lasting.

There are many treatment options for HC caused by radiation or chemotherapy. In most cases, HC will respond to treatment, and your symptoms will improve after cancer therapy.

If other treatments don’t work, cystectomy can cure HC. After cystectomy, there are options for reconstructive surgery to restore urine flow. Keep in mind that needing cystectomy for HC is very rare.

There’s no way to completely prevent HC. It may help to drink plenty of water while undergoing radiation therapy or chemotherapy to keep urinating frequently. It may also help to drink one large glass of cranberry juice during treatments.

Your cancer treatment team may try to prevent HC in several ways. If you’re having pelvic radiation therapy, limiting the area and the amount of radiation may help prevent HC.

Another way to lower risk is to put a medication into the bladder that strengthens the bladder lining before treatment. Two medications, sodium hyaluronate and chondroitin sulfate, have had some positive results.

Reducing the risk of HC caused by chemotherapy is more reliable. Your treatment plan may include these preventive measures:

  • hyperhydration during treatment to keep your bladder full and flowing; adding a diuretic may also help
  • continual bladder irrigation during treatment
  • administration of the medication Mesna before and after treatment as an oral or an IV medication; this drug binds to acrolein and allows the acrolein to move through the bladder without damage
  • cessation of smoking during chemotherapy with cyclophosphamide or ifosfamide