Bladder Instillations and Washouts

Various solutions are available as irrigations or washouts. Exfoliation rates of urothelial cells following bladder irrigation have been studied in patients with long-term indwelling catheters and chronic urinary tract infections (UTI). The irrigations were associated with an increased shedding of urothelial cells, further damaging the already disrupted urothelium, which may in turn increase the predisposition of the bladder to the recurrent infections.¹

• Sterile sodium chloride solution 0.9% - physiological saline, is usually adequate and is the preferred mechanical irrigant.
• Aqueous chlorhexidine may be used in the management of common infections of the bladder. It is ineffective against most pseudomonas organisms. Solutions containing chlorhexidine 0.02% are used, but they may irritate the mucosa and cause burning and haematuria. In these cases they should be discontinued. In a study examining the efficacy of peri-operative intermittent bladder irrigation with 0.05% chlorhexidine gluconate solution in the prevention of post-prostatectomy infective complications in men with pre-operative indwelling urinary catheters, the irrigation was able to reduce significantly the incidence of intra-operative bacteraemia and severe wound infection.² septicaemia was absent and post-operative urinary catheter requirements and hospital stay were shortened. Bladder mucosal biopsies revealed that 0.05% chlorhexidine used on intermittent basis caused no injuries. This is not for use in other body cavities. Alcoholic solutions are not suitable for use before diathermy.
• Amphotericin (50 micrograms/ml) may be of value in mycotic infections as a continuous bladder irrigation. Amphotericin is used for the treatment of systemic fungal infections and is active against most fungi and yeasts. It is highly protein bound and penetrates poorly into body fluids and tissues. When given parenterally amphotericin is toxic and side-effects are common.
• When giving amphotericin parenterally, toxicity is common and close supervision is necessary. A test dose is required. If used in renal impairment hepatic and renal-function tests, blood counts, and plasma electrolyte ( plasma-potassium and magnesium concentration) monitoring is required. Avoid using with corticosteroids- except to control reactions.Avoid also in pregnancy and breast-feeding. Rapid infusion should be avoided as there is a risk of arrhythmias.
• Side-effects (most common when given parenterally) include:
  • Anorexia, nausea and vomiting, diarrhoea, epigastric pain
  • Disturbances in renal and liver function
  • Renal and cardiovascular toxicity including arrhythmias
  • Blood disorders
  • Neurological disorders- including hearing loss, diplopia, convulsions and peripheral neuropathy

Treatment should be discontinued if they occur.
Bladder instillations of Hyaluronic Acid (HA) have had a significant effect on the rate of UTI in women with a history of recurrent UTIs in recent research.³ The bladder instillation of HA was found to be an acceptable therapeutic alternative in patients with recurrent UTI. (Placebo controlled clinical trials examining this application of HA are currently underway)

• Clot retention is usually treated by irrigation with sterile sodium chloride solution 0.9%
• Sterile sodium citrate solution for bladder irrigation 3% may also be helpful
• Streptokinase-streptodornase (Varidase Topical® ) is an alternative but was discontued in the UK in April 2006. Contra-indications include active haemorrhage and severe hypertension. Side-effects include infrequent allergic reactions (reduced by careful and frequent removal of exudate and thorough irrigation with physiological saline), fever, transient burning, haemorrhage and hypersensitivity reactions including shock have been reported.

Superficial bladder cancer can be treated surgically, but patients are at high risk for recurrence. Tumours are categorized as low, intermediate, and high-risk based on grade, stage, and pattern of recurrence. Low-risk tumours are best treated with a single instillation of chemotherapy - thiotepa, doxorubicin, or mitomycin⁴

• Doxorubicin and epirubicin are anthracycline antibiotics. Many cytotoxic antibiotics act as radiomimetics and simultaneous use of radiotherapy should be avoided as it may result in markedly enhanced toxicity. Doxorubicin is used to treat the acute leukaemias, lymphomas, and a variety of solid tumours. Doxorubicin is largely excreted by the biliary tract, and an elevated bilirubin concentration is an indication for reducing the dose. Doxorubicin is given by bladder instillation for the treatment of transitional cell carcinoma, papillary bladder tumours and carcinoma in-situ.
• Instillation of epirubicin is used for treatment and prophylaxis of certain forms of superficial bladder cancer. Epirubicin is structurally related to doxorubicin.
• Mitomycin is given by bladder instillation for superficial bladder tumours. It causes delayed bone-marrow toxicity and therefore it is usually administered at 6-weekly intervals. Prolonged use may result in permanent bone-marrow damage. It may also cause lung fibrosis and renal damage.
• Alkylating drugs- thiotepa. Extensive experience is available with these drugs, which are among the most widely used in cancer chemotherapy. They act by damaging DNA, thus interfering with cell replication. In addition to the side-effects common to many cytotoxic drugs, there are two problems associated with prolonged usage. Firstly, gametogenesis is often severely affected. Secondly, prolonged use of these drugs, particularly when combined with extensive irradiation, is associated with a marked increase in the incidence of acute non-lymphocytic leukaemia. Thiotepa is usually used as an intracavitary drug for the treatment of malignant effusions or bladder cancer. Contraindications include pregnancy and breast-feeding.
• Though effective, the toxicity of bacillus Calmette-Guerin immunotherapy (BCG) restricts its use to treat higher-grade tumours.⁴ Tumours are best treated using a 3-week maintenance schedule. Patients who fail BCG may be rescued with BCG plus interferon alfa or radical cystectomy.⁵ In tumours at high risk for recurrence it is also superior to intravesical chemotherapy, but its side-effects are more pronounced.⁶ Side-effects of BCG immunotherapy can be of both local and systemic nature. There is a report the first case of Henoch-Schonlein purpura following intravesical administration of BCG.⁷ Side-effects do not increase over time. The ideal schedule for BCG has not yet been found.

Such instillations reduce systemic side-effects, however adverse effects on the bladder such as micturition disorders and reduction in bladder capacity may occur.

Dimethyl sulfoxide (dimethyl sulphoxide) may be used for symptomatic relief in patients with interstitial cystitis ( IC or Hunner's ulcer). 50 ml of a 50% solution (Rimso-50&reg, available on named-patient basis from Britannia) is instilled into the bladder, retained for 15 minutes, and voided by the patient. Treatment is repeated at intervals of 2 weeks. Bladder spasm and hypersensitivity reactions may occur and long-term use requires ophthalmic, renal, and hepatic assessment at intervals of 6 months. There is little evidence of its efficacy. Newer therapies are being studied and a recent study demonstrated both that prolonged intravesical instillation of a drug (by in situ drug delivery system ) was a feasible procedure and also supported the efficacy of Resiniferatoxin (RTX) in the treatment of IC patients. However further studies are necessary to define the exact action mechanism of prolonged infusion of RTX, the dosage and the treatment schedule.⁸