High doses of radiotherapy for bladder, cervix or endometrial cancer give a risk of bladder changes. 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.

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)
• can’t wait when you need to empty your bladder (urgency)
• blood in your urine (haematuria).

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

• a small amount of urine leakage (incontinence) – especially if you laugh, sneeze or exercise
• pain when passing urine
• passing blood clots.

You may have difficulty passing urine, because the radiotherapy can make the the tube that drains urine from the bladder (urethra) narrower. This is known as a stricture.

Many of these problems can be dealt with successfully. The appropriate treatment will depend upon 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.

If you want to go to the toilet more often or feel that you can’t wait when you do want to go, you can get a card to show to staff in shops or pubs etc. The card allows you to use their loos, without them asking awkward questions. You can get the cards (and a map of all the toilets) from Incontact, RADAR or the Continence Foundation.

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 This is in tea, coffee, cola and some painkillers. Caffeine stimulates the nerves of the bladder. 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 may make symptoms worse for some people. The same advice applies as with caffeine.
• Drink normal amounts of fluids. You may want to cut back on the amount that you drink so your bladder does not fill up so quickly. However, this can make symptoms worse as the urine becomes more concentrated and iritates 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.
• Get your doctor to do a urine test to make sure you haven't got an infection
• Avoid spicy food
• Reduce or give up smoking – this can be difficult at a stressful time. If you need help you can contact QUIT
• Find ways of reducing stress, as stress 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.

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.

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. Then you can 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. A cystoscopy allows the doctors to see inside the bladder using a flexible, tube with a light and lens at the end which is passed through your urethra (the tube that drains urine out of the bladder). Usually, a cystoscopy is done under a local anaesthetic.

Leakage of urine from the bladder 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.
Some of the following may help:

Pelvic floor exercises

Exercises to retrain the bladder, or pelvic floor exercises, may help to 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 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 Continence Foundation.

First, you need to identify the muscles that need to be exercised. Do this by tightening the muscles around your back passage, vagina and urethra and lift up inside. It is as if you are trying to stop passing wind and urine at the same time. You don’t want to exercise any other muscles in the area, so

• don’t pull your tummy in
• don’t squeeze your legs together,
• don’t tighten your buttocks
• don’t hold your breath.

Try holding the muscles tight for as long and as hard as you can. Build up to a maximum of 10 seconds. Rest for four seconds and then tighten the muscles again as many times as you can, up to a maximum of 10 times.

Try doing these exercises in a slow and controlled way with a rest of four seconds between each muscle tightening. Practise your maximum number (up to 10) about six times each day.

Quick squeezes It is important to be able to work the pelvic floor muscles quickly to help them react to sudden stresses that put pressure on the bladder, such as coughing, laughing or exercise. So you need to practise some quick tightenings of these muscles. You can do this by quickly tightening the pelvic floor and holding for just one second before releasing the muscles. Do these in a steady way: aim for a strong muscle tightening with each contraction (up to a maximum of 10 times).

Aim to do one set of slow squeezes followed by one set of quick squeezes six times each day.

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 (you could have an unlabelled simple tick chart on a kitchen pin board) 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.

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

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. These include oxybutynin, tolterodine, trospium chloride, propiverine, and 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. Continence advisers, specialist nurses and Cancerbackup can advise you on caring for your skin if it gets sore.

You may have to pass urine very often after pelvic radiotherapy. The bladder may 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.

Bladder retraining Bladder retraining means training yourself to ignore the feeling of needing to pass urine, so that your bladder gets used to feeling more full. This can mean that you do not need to go to the toilet so often and it also reduces the chance of leaking urine. Bladder training can be difficult, but gets easier with time 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 the amount (volume) that 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 start, go to the toilet as usual for 2–3 days at first. You can 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 100–200 ml.

After 2–3 days, the aim is then 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
• 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 between going 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 250–300 mls 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.

The urethra (tube that drains urine from the bladder) can get narrower after 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.

If you are passing blood in your urine, you will need to have a cystoscopy to find out why the bleeding is happening. If the bleeding is caused by radiation damage to the walls of the bladder and is only slight or occasional, no treatment may be needed. If the bleeding occurs often or is heavier, or is making you anaemic, taking tranexamic acid 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 also be possible to stop the bleeding by putting a particular liquid into the bladder through a catheter. This can be uncomfortable, but should not be painful. 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.

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. Intense heat is applied to the area 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.

If the side effects continue or are not controlled by 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 very rare.