Intractable Bladder Hemorrhage: Providing a Treatment Algorithm for a Complex Clinical Problem

Information about the frequency, intensity, prevention, treatment, and management of bladder hemorrhages, especially in patients with advanced bladder carcinoma, is lacking or scarce. The main treatment options are classified as intravesical treatment attempts using several chemical agents, placement of intrabladder compression balloon, hyperbaric oxygen treatment, transarterial embolization, or surgery. In view of the differences between patients with regard to the causes of bleeding, immediate treatment options, availability of the treatment modalities in each institution, life expectancy of the patient, and accompanying comorbidities, the management of each patient should be arranged individually. Nevertheless, based on the current literature, a treatment algorithm may be developed for these patients. The first step would be intravesical irrigation with substances with few side effects or intravesical balloon pressure treatment. If this treatment does not yield the expected result, hyperbaric oxygen therapy may be conducted in hemorrhagic cystitis or radiation cystitis patients; otherwise, transarterial embolization, the efficacy and safety of which are well-reported, should be performed. In these patients, application of surgical techniques and intravesical formalin are the last resorts.