Bladder problems after pelvic radiotherapy

The cells lining the walls of the bladder can become permanently damaged. This can make them fragile, so they may bleed. The bladder walls may also become scarred and hardened (fibrosed). If this happens, the bladder holds less urine.

After pelvic radiotherapy, the flow of urine may be weaker and your bladder may not empty completely. You may need to get up often to pass urine in the night. You may also have difficulty passing urine because the radiotherapy can make the tube that drains urine from the bladder (urethra) narrower. This is known as a urethral stricture.

You may find that you have some of the following:

• a need to pass urine often (frequency)
• a burning sensation when you pass urine (similar to cystitis)
• not being able to wait when you need to empty your bladder (urgency)
• a small amount of urine leakage (incontinence) - especially if you laugh, sneeze or exercise
• blood in your urine (haematuria).

You may have other symptoms, but these are much less common:

• pain when passing urine
• passing blood clots.

Many of these problems can be dealt with successfully. The appropriate treatment will depend on which symptoms or side effects you have and how much of a problem they are. Medicines such as antibiotics and painkillers can be prescribed if needed.

Dealing with bladder problems Back to top

After radiotherapy, the bladder irritation usually settles down over a few weeks or months once the treatment has ended. The following tips can help reduce bladder irritation:

• Avoid caffeine Caffeine stimulates the nerves of the bladder. It’s found in tea, coffee, cola and some painkillers. It may be worth giving up caffeine for a week or so to see if your bladder symptoms get better. If things improve, you don’t need to give up caffeine completely, but you may want to limit the times that you have caffeine drinks. You can also plan to be near to a toilet whenever you do have caffeine.
• Avoid alcohol Alcohol can make symptoms worse for some people. The same advice applies as with caffeine.
• Drink normal amounts of fluids. It’s tempting to cut back on the amount that you drink so your bladder doesn’t fill up so quickly. However, this can make symptoms worse as the urine becomes more concentrated and irritates the bladder lining. Aim to drink normal amounts of fluids each day. This is usually about two litres of liquid a day – about 6–8 cups of fluid. You may need more in hot climates and hot weather.
• Reduce or give up smoking This can be difficult at a stressful time. If you need help you can contact QUIT. We have more information about giving up smoking after cancer treatment.
• Find ways of reducing stress, as this can increase the feeling of needing to pass urine.
• Avoid constipation as this causes pressure on the bladder.
• Keep a diary to show how much you are drinking and how often you pass urine.

If you are still having problems three months after the treatment has ended, let your doctor or specialist nurse know.

Cranberry Juice

It has been suggested that cranberry juice may help to prevent urinary infections. Some people feel that it helps them, but there is no strong research evidence to back this up. If you are taking medicine to thin your blood, such as warfarin, you should avoid cranberry juice as it can increase the effects of the medicine and may cause potentially harmful side effects. It is also high in sugar so is not suitable for people with diabetes.

Tests for bladder problems Back to top

If you develop any new bladder problems after your treatment, or if any immediate side effects get worse, your doctors will probably want you to have some tests to find out what is causing the problem. This may include blood and urine tests, a cystoscopy and special x-rays of the bladder and kidneys. During a cystoscopy, the doctor uses a thin, flexible fibre-optic tube with a light on the end (cytoscope) to look at the inside of the bladder. This tube is passed through your urethra which is the tube that drains urine out of the bladder. Usually, this is done under a local anaesthetic.

Leakage of urine Back to top

Leakage of urine is quite common after pelvic radiotherapy. The chance of leakage depends on the type of cancer and the dose of the radiotherapy. You may find that you only leak urine when you laugh, sneeze or exercise. This is usually because the valve and muscles that keep the bladder closed become weaker after radiotherapy. Some urine then leaks out if pressure is put on the bladder. This is known as stress incontinence.

Pelvic floor exercises

Exercises to retrain the bladder, or pelvic floor exercises, may help relieve incontinence. A brief description of the exercises is given here. However, a physiotherapist or community continence adviser can give you more detailed information. They can also can help you check you are doing the exercises properly – this can make them more effective. You can get details of your nearest continence clinic or adviser from The Bladder and Bowel Foundation|.

First, you need to identify the muscles that need to be exercised. Do this by sitting comfortably with your knees slightly apart. Then imagine that you are trying to stop yourself passing wind from the bowel. To do this, squeeze the muscle around the back passage. Try squeezing and lifting that muscle as tightly as you can. You should be able to feel the muscle move. If you can’t feel a definite squeeze and lift action in your pelvic floor muscles, you can ask to see a physiotherapist or continence adviser. They can help you get your pelvic floor muscles working properly.

When you can feel the muscles working, you can start to exercise them:

• Tighten and pull in strongly the muscles around the anus and the urethra. Lift them up inside. Try and hold this contraction strongly as you count to five.
• Release the muscles slowly and relax for a few seconds. You should have a definite feeling of 'letting go'.
• Repeat (squeeze and lift) and relax. It is important to rest between each contraction. If you find it easy to squeeze for a count of five, try to hold for longer – up to ten seconds.

Do these exercises – five as hard as you can, five as long as you can and as many quick pull-ups as you can – at least 10 times a day.

While doing the exercises:

• Don’t hold your breath.
• Don’t push down instead of squeezing and lifting up.
• Do your exercises carefully - fewer good exercises are more helpful than many half-hearted ones.

Get into the habit of doing the exercises regularly. You can link doing them to some everyday activities – for example, do them after emptying your bladder or whenever you turn on a tap. Try to keep a simple exercise diary (such as a simple tick chart) to help you remember. Practise the exercises when you are lying down, sitting and especially standing.

Get into the habit of tightening your pelvic floor before activities that are likely to make you leak – such as getting up from a chair, coughing, sneezing or lifting.

Tips to avoid pressure on your pelvic floor Back to top

• Avoid constipation, by eating fibre to prevent any straining during a bowel movement.
• Get medical advice for hayfever, asthma or bronchitis to reduce sneezing and coughing.
• Keep your weight within the right range for your height and age.
• Share lifting heavy loads.

Pressing urine out of the bladder Some urine may be left in the bladder after you have finished passing water. This can be pushed out by pressing up behind the scrotum and massaging the base of the penis with your thumb.

Acupuncture may also help some people to improve bladder control. Your doctor may be able to refer you for acupuncture or you can contact the British Medical Acupuncture Society|.

Anti-spasm medicines You may be prescribed a type of medicine known as an antimuscarine, such as oxybutynin, tolterodine, propiverine or solifenacin. These medicines also have different brand names. They work by blocking certain nerve impulses to the bladder. The bladder muscle then relaxes and the bladder can hold more urine.

Hygiene

Pads are available from your doctor. They may be available on the NHS or you may need to pay for them. Continence advisers, specialist nurses and our cancer support specialists can advise you on caring for your skin if it gets sore.

Needing to pass urine often and at night Back to top

You may have to pass urine more frequently after pelvic radiotherapy. The bladder can be more sensitive and may feel like it is full of urine when there is not much urine there. This is known as an overactive bladder. Several things can help:

Anti-spasm medicines can help with frequency and urgency.

Pelvic floor exercises

Bladder retraining This means training yourself to ignore the feeling of needing to pass urine, so that your bladder gets used to fuller. This can mean that you don't need to go to the toilet so often and it also reduces the chance of leaking urine. Bladder training can be difficult, but it gets easier if you practice. It works best if combined with advice and support from a continence adviser, nurse, or doctor.

You will need to keep a diary. In the diary make a note of the times you pass urine, and how much you pass each time. Also make a note of the times you leak urine. Your doctor, nurse or continence adviser may have some diary-charts you can use.

When you first start, go to the toilet as usual for 2–3 days at first. You can then see how often you go to the toilet and how much urine you normally pass each time. If you have an overactive bladder you may be going to the toilet every hour or so. Each time you may pass less than 100–200ml.

After the 2–3 days, the aim is to 'hold on' for as long as possible before you go to the toilet. This will seem difficult at first. It may be quite uncomfortable and difficult to stop going to the toilet when you feel you want to. When you are trying to hold on, you can distract yourself by:

• sitting straight on a hard seat
• counting backwards from 100
• reading a book
• doing some pelvic floor exercises.

After a while it should become easier, as your bladder gradually gets used to holding larger amounts of urine. The idea is to gradually extend the time before you go to the toilet. It may take several weeks, but the aim is to pass urine only 5–6 times in 24 hours and to pass up to 250–300mls each time. After several months you may find that you just have the normal feelings of needing to go to the toilet and can easily put them off for a reasonable time until it is convenient to go.

It can help to fill in your diary for a 24-hour period every week or so while doing the bladder training. This will record your progress. Make sure you drink a normal amount of fluids when you do bladder training.

Problems passing urine Back to top

After brachytherapy for prostate cancer the prostate gland can swell, which can reduce the flow of urine. This can be treated with a drug called Flomaxtra® that your doctor can prescribe.

The urethra (the tube that drains urine from the bladder) can get narrower after pelvic radiotherapy. This is known as a urethral stricture. It can usually be treated with a small operation. The stricture can be stretched or dilated when you are under a general anaesthetic. Usually this operation is successful but it may need to be repeated.

Blood in the urine Back to top

If you pass blood in your urine, you will need to have a cystoscopy to find out why. If the bleeding is caused by radiation damage to the walls of the bladder and is only slight or occasional, you may not need any treatment. If the bleeding occurs often or is heavier, or is making you anaemic (a low number of red blood cells which can make you breathless and tired), taking tranexamic acid (Cyklokapron®) tablets can sometimes help. Your doctor may prescribe these for you. They are usually taken three times a day and have few side effects.

It may be possible to stop the bleeding using particular liquids that are put into the bladder through a catheter (intravesical treatment). This can be uncomfortable, but should not be painful. Different liquids can be used and your doctor will explain the treatment to you, and any possible side effects, if they think that you need to have this treatment.

If the bleeding continues or if you are passing blood clots, you may need to have a catheter so that a liquid can be passed into the bladder to flush out the clots. This procedure is known as a bladder wash-out. Your nurse or doctor can can explain it in more detail if it is needed.

If these treatments don’t stop the bleeding, the areas within the bladder that are bleeding can be cauterised during a minor operation using a cystoscope. cauterising involves applying heat to the area that is bleeding using an electrical current or laser. If the bleeding carries on, other treatments such as blood transfusions| or hyperbaric oxygen therapy| may be needed, but this is very rare. We can give you information about both of these treatments.

Continuing bladder problems Back to top

If the side effects continue or don't respond to initial treatments, your doctor or nurse will be able to explain the other treatments that are available. Surgery may be needed. In extreme circumstances it may be necessary to remove the bladder, but this is extremely rare.

Coping with bladder problems when away from home

If you need to go to the toilet more often and feel you can't wait, you can get a public toilet key that gives you access to around 7,000 locked public toilets around the country. This can help you to get into toilets quickly and can help you feel less worried when you go out. You can also get a Just Can't Wait card to show to staff in shops and pubs etc. The card explains that you have a medical condition that requires urgent need of a toilet.

You can get a toilet key or a Just Can't Wait card from The Bladder and Bowel Foundation| or RADAR|.