Introduction: Radiation cystitis is one of the late toxicities of pelvic radiation. Cervical cancer is the most common pelvic malignancy in India, and it is not uncommon to find the sequela after External Beam Radiotherapy and brachytherapy depositing over 60 to 65 Gy in bladder tissue. This sequela usually appears 6 months to 1 year after pelvic radiation and the risk remains till the patient is alive. We report a case of radiation cystitis 21 years after cervical cancer treatment. This is very rare in the sense that most patients present with this complication within few years of treatment.
Clinical findings: 62 year old woman was admitted to emergency department with history of bleeding in urine (Painless hematuria) and weakness for 10 days. She had no comorbidity and gave history of cervical cancer treatment in cobalt-60 machine followed by LDR brachytherapy in 2000. She had no records of her treatment; hence the dose of radiation and other details could not be ascertained. However roughly 80-85 Gy to high-risk Planning Target Volume (HR PTV) and over 65 Gy bladder dose is quite a possibility. Her vitals were normal except blood pressure, which was on lower side, 90/72 mm Hg and she was anemic. Abdominal and per vaginal examination were normal, except stenosed vagina.
Diagnosis & Treatment: Routine blood counts, liver function test and kidney function tests were normal except hemoglobin, 8.2 gms/ml. A contrast enhanced CT scan of abdomen and pelvis revealed a large clot/growth in urinary bladder. Urinary bladder malignancy could be a possibility at her age. After saline bladder irrigation, we performed a cystoscopy which showed a small clot in bladder and few areas of telangiectasis, definitive sign of radiation cystitis. Bladder irrigation, a course of antibiotics, ethamsylate and IV iron were administered along with two pints of whole blood. Within 5 days she gained strength and discharged with hemoglobin of 10.5 mg/ml and no active bleeding in urine She was advised to visit next month or early in case of bleeding.
Conclusions: Radiation cystitis is a late toxicity of pelvic radiation which can appear any time after 6 months of radiation treatment and the risk remains till the patient is alive. It can mimic a second primary cancer of urinary bladder and needs careful differentiation. Symptomatic and supportive care resolves most cases.

Radiation cystitis after 21 years of pelvic radiation