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Preparing for BCG Therapy: A Practical Guide to Expect Before, During, and After

  • Writer: Polygon Health Team
    Polygon Health Team
  • May 5
  • 14 min read

Bladder cancer, particularly in its early stages where the tumor is confined to the inner lining of the bladder and has not invaded the muscle wall (non-muscle invasive bladder cancer or NMIBC), is commonly treated with an immunotherapy known as BCG therapy.1 BCG, short for Bacillus Calmette-Guérin, is a weakened form of bacteria that is related to the germ that causes tuberculosis (TB) but does not typically cause serious disease.1 This therapy works by stimulating the body's immune system to target and destroy cancer cells within the bladder lining, thereby preventing or delaying the cancer from recurring or becoming more invasive.3 It is often administered directly into the bladder through a catheter, a procedure known as intravesical therapy, following the surgical removal of visible bladder tumors through a procedure called Transurethral Resection of Bladder Tumor (TURBT).1 The initiation of BCG treatment typically occurs 2 to 4 weeks after the TURBT procedure to allow sufficient time for the bladder to heal.1 This guide aims to provide individuals preparing for BCG therapy with practical information about what to anticipate before, during, and after the treatment.


The standard initial schedule for BCG therapy is known as the induction course.1 This course typically involves weekly instillations of the BCG solution into the bladder for a duration of six weeks.1 This initial phase is critical for effectively stimulating the immune system to recognize and combat the cancer cells.3 Following the induction course, many patients may undergo maintenance therapy.2 Maintenance therapy involves periodic BCG instillations, typically occurring every few weeks or months, for a duration ranging from one to three years.2 The purpose of maintenance therapy is to further reduce the risk of the cancer recurring or progressing to a more advanced stage.4 The frequency of these maintenance treatments usually decreases over time; for instance, treatments might initially be monthly.13 Some common maintenance schedules include weekly treatments for three weeks at the 3-, 6-, and 12-month marks 19, or a schedule extending up to 36 months with treatments at 3, 6, 12, 18, 24, 30, and 36 months after the initial treatment.8 It is important to note that the specific treatment schedule, including both the induction and maintenance phases, can vary depending on individual factors such as the grade and stage of the cancer, the patient's risk of recurrence, and the treating physician's recommendations.2 While the initial six-week induction course is a standard approach, the long-term maintenance strategy is often tailored to meet the unique needs of each patient and their likelihood of cancer recurrence.2


Preparing for your first BCG treatment involves several important steps in the days and weeks leading up to the appointment.1 For individuals receiving BCG therapy for the first time, a chest X-ray is typically required before starting treatment.1 This precaution is likely taken to screen for any active tuberculosis infection, given the relationship between BCG and the bacteria that cause TB. It is also crucial to inform your doctor about all medications you are currently taking, including prescription drugs, over-the-counter medications, and any complementary or herbal therapies, as certain medications can potentially interact with BCG treatment.1 For instance, the blood-thinning medication warfarin is known to have interactions with BCG.13 Patients who regularly take diuretics, also known as water tablets, are generally advised to take them after their BCG treatment session.1 Before the treatment begins, your medical provider will thoroughly explain the procedure, discuss potential risks and benefits, and obtain your informed consent.1 This is an opportune time to ask any questions or express any concerns you might have about the therapy.13


On the day of your BCG treatment appointment, there are specific instructions to follow to ensure the procedure is as effective and comfortable as possible.1 It is generally recommended to limit your fluid intake for 4 to 8 hours prior to the treatment.1 This helps to concentrate the BCG solution in your bladder and makes it easier to retain it for the required duration.14 You should also avoid consuming caffeinated beverages for 6 to 8 hours before the appointment, as caffeine can increase the urge to urinate.1 Fasting is not necessary before the procedure.1 If you are taking diuretics, it is usually recommended to withhold them before the procedure unless your doctor has specifically instructed otherwise.1 You will be asked to arrive at the clinic with some fluid in your bladder as you will need to provide a urine sample. This sample will be tested for the presence of any urinary tract infection (UTI).1 If a UTI is detected, the BCG treatment will likely be postponed until the infection has been treated and cleared.1 It is also important to inform your nurse or doctor if you have experienced any fever, chills, or unusual tiredness since your last appointment, or if you have noticed blood in your urine before your scheduled treatment, as these factors might necessitate a postponement.1


A typical BCG therapy session involves a relatively straightforward administration process.1 The treatment usually takes place in the outpatient department of a hospital or at a cancer day clinic.4 Upon arrival, you will typically be asked to provide a urine sample for infection check and to empty your bladder.1 A nurse or doctor will then clean the area around your urethra with an antiseptic solution before gently inserting a thin, flexible tube called a catheter through the urethra and into your bladder.1 To minimize discomfort during this process, a local anesthetic gel may be applied.4 You might experience a mild feeling of discomfort during the catheter insertion.23 Next, the liquid BCG medication will be slowly instilled into your bladder through the catheter using a syringe.1 As the BCG solution enters your bladder, you might feel a cool sensation.21 Once the medication has been administered, the catheter is usually removed immediately.1 In some instances, the catheter might be left in place and clamped for the duration of the treatment retention period.20 You will be instructed to try not to urinate for approximately two hours (up to two hours) to allow the BCG to remain in contact with the bladder lining and exert its therapeutic effect.1 If you feel the need to urinate before the two-hour mark, it is still considered beneficial to hold it for at least one hour.1 It is important not to try to hold the medication for longer than two hours.1 To ensure the BCG reaches all areas of the bladder lining, you might be asked to change your body position every 15 minutes during the first hour of the retention period, alternating between lying on your stomach, back, and each side.4 Alternatively, you might be advised to get up and move around after an initial period of lying on your stomach.25 Generally, you are permitted to walk around during the two-hour retention period.14 Depending on your proximity to the hospital and your comfort level, some centers may allow you to return home with the medication in your bladder and pass urine at home after the two-hour retention time.14 The entire treatment session typically lasts a little over two hours, after which you will be able to go home.13 Your first treatment appointment might take slightly longer, potentially up to three hours.17 During the session, you might experience some common sensations, including mild discomfort during catheter insertion and removal 23, a feeling of fullness or slight discomfort in your bladder while holding the solution 15, and the cool sensation as the liquid enters your bladder.21


Patients undergoing BCG therapy may experience several common side effects during and immediately after treatment.1 One common side effect is bladder irritation, which can feel similar to a urinary tract infection.3 This irritation can lead to an increased frequency and urgency of urination (pollakiuria) 3, as well as pain or a burning sensation when passing urine (dysuria).1 It is also common to observe blood or debris in the urine (hematuria) 1, which is usually mild and temporary.1 Many individuals experience flu-like symptoms for 24 to 48 hours after each BCG treatment 1, including fatigue, tiredness, weakness, chills, a mild fever (typically below 101°F or 38.3°C), muscle or joint pain, and a general feeling of being unwell (malaise).1 Some patients might also experience an upset stomach, nausea, vomiting, or a decrease in appetite 3, and there might be some discomfort in the genital area where the catheter was inserted.23 It is important to remember that these side effects are usually mild and temporary, often subsiding within 24 to 48 hours.5 However, it is advisable to monitor your symptoms and to inform your doctor or nurse about any side effects you experience, especially if they persist or worsen, as they may be able to provide guidance and treatment to help manage them.14


While the common side effects of BCG therapy are typically mild and short-lived, there are potential long-term side effects, although these are less frequent.4 In rare instances, the BCG bacteria can spread throughout the body, leading to a more serious infection resembling tuberculosis, which necessitates medical treatment.4 This condition, known as BCG sepsis or disseminated BCG infection, may not manifest symptoms for months or even years after the completion of therapy.31 General symptoms can include fever and chills, pain in the joints or muscles, nausea or vomiting, a persistent cough, skin rash, extreme fatigue, and possibly shortness of breath.5 Localized infections can also occur, such as granulomatous prostatitis (inflammation of the prostate gland) or epididymitis (inflammation of the epididymis).31 In rare cases, renal complications like nephritis (kidney inflammation), ureteral obstruction (blockage of the ureter), acute renal failure, or acute renal injury may occur.38 Musculoskeletal issues, such as osteomyelitis (bone infection), reactive arthritis, Reiter's syndrome, and polyarthritis, are also rare potential long-term side effects.31 Pulmonary complications like pneumonitis (lung inflammation) are uncommon 14, as are hepatic complications such as hepatitis (liver inflammation).5 Bladder contracture, a condition where the bladder becomes scarred and shrinks, is an uncommon long-term effect.31 Hydronephrosis, the swelling of a kidney due to a buildup of urine, is another rare potential long-term complication.38 It is crucial to inform any healthcare provider about your history of BCG treatment should you develop any new or concerning symptoms, even if it is months or years after you completed the therapy.5


To help manage the side effects of BCG therapy, several practical tips and recommendations from medical sources can be helpful.1 For bladder irritation and urinary symptoms, it is advisable to drink plenty of fluids (2-3 liters or 6-8 glasses) after each treatment for at least 6-8 hours, and ideally for 24 hours, unless your doctor advises otherwise.4 This helps to flush the system and can ease burning and frequent urination.4 Avoiding caffeine, alcohol, and spicy foods for the first 1-2 days after treatment can also help as these can irritate the bladder.23 Over-the-counter pain relievers such as acetaminophen (Tylenol) can be used to manage pain and discomfort during urination.21 If symptoms persist or are severe, your doctor may prescribe medications like antispasmodics or analgesics.26 For managing flu-like symptoms, getting plenty of rest, especially on the day of treatment and the day after, is recommended.11 Over-the-counter medications like acetaminophen or ibuprofen can help reduce fever, aches, and muscle or joint pain.4 It is also important to stay hydrated by drinking plenty of fluids.13 If you notice blood in your urine, continue to increase your fluid intake to help keep your urine clear and prevent clots.26 Mild blood in the urine immediately after the procedure is common 16 and usually resolves within 24-48 hours.26 However, you should contact your doctor if you experience heavy bleeding or if the blood persists for more than a few days.14 To prevent the potential spread of BCG, especially for the first six hours after treatment, it is important to sit down to urinate to avoid splashing, particularly for men.4 After urinating, pour 2 cups (or half a pint as suggested by some sources 14) of undiluted household bleach into the toilet bowl, wait 15-20 minutes, and then flush with the lid closed.1 Make sure to wash your hands and the genital area immediately with soap and warm water after passing urine.4 Avoid using public restrooms during this 6-hour period.17 If any clothing gets splashed with urine, wash it separately in bleach and warm water.13 If you use incontinence pads, pour bleach on the used pad before disposing of it in a sealed plastic bag.13 It is generally advised to avoid sexual intercourse for at least 24-48 hours after each treatment.14 To protect your partner, your doctor may recommend using a condom for vaginal, anal, or oral sex for a week after each treatment.13 It is crucial to contact your healthcare team immediately if you experience any of the following: a high fever (over 100.5°F or 38°C) lasting more than 48 hours, severe chills or shaking, inability to pass urine for 6 hours or longer, worsening lower stomach pain or bladder spasms after 48 hours, signs of infection (cloudy or offensive-smelling urine, persistent symptoms), shortness of breath or difficulty breathing, skin rash or allergic reaction, severe pain, confusion or dizziness, cough, or joint pain that persists or worsens.1


Following the completion of your initial six-week induction course of BCG therapy, a schedule of follow-up appointments and monitoring procedures will be implemented.3 Typically, you will have a cystoscopy, a procedure where a small camera is used to examine the inside of your bladder, approximately 4 to 12 weeks (often around 6 weeks) after finishing the initial treatment.3 This allows your doctor to assess how well the treatment has worked and to check for any remaining signs of cancer. During the cystoscopy, small tissue samples (biopsies) might be taken for further examination.20 If the BCG treatment has been effective and you are considered to be at high risk for the cancer returning, your doctor may recommend a course of maintenance BCG therapy to provide ongoing protection for your bladder.16 This maintenance therapy usually involves less frequent BCG instillations over a longer period, such as once a week for three weeks at the 3, 6, 12, 18, 24, 30, and 36-month marks after your initial treatment.8 The specific schedule for maintenance therapy can vary; for example, some protocols involve three weekly doses at 3 months, followed by treatments every 6 months for up to 2 or 3 years.18 Guidelines from the European Association of Urology (EAU) suggest a maintenance schedule of three weekly instillations at 3, 6, 12, 18, 24, 30, and 36 months based on available research.22 Even after you complete maintenance therapy, you will continue to have follow-up appointments, which may include regular cystoscopies and urine tests to monitor for any potential recurrence of the bladder cancer.3 The frequency of these follow-up appointments will be determined based on your individual risk factors and how well you responded to the BCG treatment.1 Urine tests to check for the presence of cancer cells might also be a part of your routine monitoring schedule.28


For those seeking more information about BCG therapy, several reputable medical organizations, cancer centers, and patient advocacy groups offer reliable resources.3 These include major cancer organizations such as the American Cancer Society (cancer.org) 7, the National Cancer Institute (cancer.gov) 45, Cancer Research UK (cancerresearchuk.org) 14, Macmillan Cancer Support (macmillan.org.uk) 15, and Cancer Council Australia (cancercouncil.com.au).13 Leading cancer centers like Memorial Sloan Kettering Cancer Center (mskcc.org) 3, City of Hope (cityofhope.org) 4, Cleveland Clinic (my.clevelandclinic.org) 19, Mayo Clinic (mayoclinic.org) 51, and Johns Hopkins Medicine (hopkinsmedicine.org) 52 also provide valuable information. Urological associations such as the American Urological Association (auanet.org) 9 and the Society of Urologic Nurses and Associates (SUNA) (suna.org) 12 are excellent resources. Patient advocacy groups like the Bladder Cancer Advocacy Network (BCAN) (bcan.org) 11 and Action Bladder Cancer UK (actionbladdercanceruk.org) 20 offer patient-focused information and support. Additionally, medical information websites like MedlinePlus (medlineplus.gov), WebMD (webmd.com) 32, Drugs.com (drugs.com) 31, and Healthline (healthline.com) 30, as well as research databases such as PubMed (pubmed.ncbi.nlm.nih.gov) 40 and PMC (PubMed Central) (ncbi.nlm.nih.gov/pmc/) 8, can provide comprehensive and reliable information about BCG therapy.


In conclusion, BCG therapy stands as a cornerstone in the treatment of early-stage, non-muscle invasive bladder cancer, playing a vital role in preventing the recurrence of the disease following tumor removal. Understanding what to expect at each stage of this treatment journey, from the initial preparation and the administration process to the potential side effects and the importance of follow-up care, can significantly empower patients. Maintaining open and consistent communication with your healthcare team is paramount throughout your BCG therapy. Do not hesitate to ask questions, report any side effects you experience, or voice any concerns. Your medical team is there to support you and guide you through every step. While undergoing BCG therapy may present certain challenges, being well-informed about what to anticipate can foster a greater sense of preparedness and control, ultimately contributing to a more positive and effective treatment experience.


Works cited


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