BCG: maintenance treatment

BCG (Bacillus Calmette Guerin) is a live, weakened bacteria which is used to vaccinate against TB (tuberculosis). It works by stimulating your body to fight the infection. It is also used to treat bladder cancer.

To find out more see BCG: induction (starter) treatment.

Typical maintenance schedule

Your maintenance treatment consists of the following, which will start about a month after your flexible cystoscopy.

• To begin: 3 BCG treatments, given once a week for 3 weeks (week 1, week 2 and week 3). 
• 3 months later: a repeat course of 3 (weekly) BCG treatments.

After that we may need to repeat this 3-week BCG course every 6 months. This maintenance treatment can continue for up to 3 years.

We will discuss the best schedule of treatment with you.

About each individual treatment

• Each treatment takes about 20 minutes.
• Treatment takes place at the Urodynamics Unit or Albany Unit. Your appointment letter will tell you which Unit to go to.

Preparing for treatment

Vaccines

Do not have flu or holiday vaccines for 14 days before or after your BCG treatments. (Vaccines can over-stimulate your immune system and stop the BCG treatment from being effective.)

Fluids

By drinking less you will produce less urine, and prevent the BCG drug from becoming too diluted. This will improve its effectiveness. Drinking less will also make it easier for you to hold onto the drug once it is in your bladder.

Water tablets (diuretics)

If you usually take water tablets in the morning, do not take them before your treatment (unless we tell you otherwise). You can take them when you are home after your BCG treatment.

High blood pressure tablets (antihypertensives)

If you usually take blood pressure tablets every day, do not take them on the morning of your treatment.

(These tablets can cause a drop in blood pressure when combined with this treatment, and may cause you to fall or faint.)

You can take your tablets later in the day, when you start to drink. (See 'Drinking fluids/pain/sexual activity', below).

Eating

You can have solid food before your treatment, but no fluids. Do not drink milk, tea or coffee.

Driving

You can drive yourself home after each treatment.

On the day

When you arrive at the Unit, we will ask you a few questions. We will ask you to provide a urine sample. 

You can bring a sample with you from home. If you do this, follow these instructions.

• Collect the sample during the middle of your urine stream.
• Collect it in a sterile container.  We usually send you one with your appointment letter. You can also buy one from any chemist.
• Your sample must be no more than 2 hours old when you give it to us.

To carry out the treatment, we will do the following.

• Insert a catheter (small, flexible tube) into your bladder through your water pipe (urethra). Most patients do not find this painful, but it can be uncomfortable.
• Pass 50mls of BCG fluid into your bladder via the catheter.
• Remove the catheter.

If you are an outpatient, you can go home after the treatment. 

Next steps at home

After 2 hours, do the following while you are home.

• After 2 hours, you must pass urine (wee) into the toilet.
• We advise men to sit when they do this, to prevent splashes.
• Do not flush the toilet immediately after you pass urine.
• Add 2 cups of undiluted bleach into the toilet after you pass urine. Leave it for 15 minutes, then flush the toilet. (We recommend bleach because BCG is a live vaccine).
• Use soap and water to wash your genital area and hands after passing urine each time.

For 6 hours after you first pass urine (wee) at home, repeat these steps:

• Continue to pass urine whenever you need to.
• Men should sit when they do this, to prevent splashes.
• Do not flush the toilet immediately after you pass urine.
• Add 2 cups of undiluted bleach into the toilet after you pass urine, leave it for 15 minutes, then flush the toilet. 
• Use soap and water to wash your genital area and hands after passing urine.

Drinking fluids/pain/sexual activity

• As soon as you have passed urine, you can start to drink. Make sure you have plenty of fluids over the next 48 hours. This will flush the rest of the BCG out of your bladder.

Tea, coffee, alcohol

• Tea and coffee can irritate the bladder. We strongly advise you not to drink caffeinated tea or coffee for the full duration of your BCG treatment (including on the day of treatment and the day after). You can drink decaffeinated tea and coffee.
• Do not drink alcohol on the day of your treatment.

Pain relief

• We advise you to take paracetamol 3 hours after your treatment. Do this even if you feel completely well. This will help to prevent you experiencing the fever or chills that can be caused by BCG. Always follow the instructions on the packaging.

Sexual activity

• If you are sexually active, do not have sexual intercourse for 48 hours after each treatment.
• We advise you to use a condom for at least 10 days after each BCG treatment, and preferably for 6 weeks after each treatment.

Side effects

Common

Common side effects usually disappear about 3 days after treatment. You can reduce some of these side effects by drinking plenty of fluids to flush the BCG out of your bladder. You can also take over-the-counter painkillers.

Common side effects include:

• needing to pass urine often
• pain when you pass urine
• blood in the urine
• flu-like symptoms such as tiredness, general aching and a raised temperature (above 38C).

If these side effects do not clear after 3 days, make a GP appointment (see also 'When to seek emergency help' below).

Less common

• a continuing high temperature (above 38C)
• vomiting
• skin rash
• coughing
• a condition called 'reactive arthritis'. This can cause painful joints, red or sore eyes or urinary tract infection (UTI) symptoms. UTI symptoms include:
  • pain or a burning sensation when peeing
  • needing to pee more often or more urgently
  • pee that looks cloudy or contains blood
  • lower tummy pain or back pain (just under the ribs)
  • a high temperature (above 38C); feeling hot/cold/shivery
  • a low temperature (below 36C).

If you experience any of these symptoms or feel generally well, speak to your GP immediately. You may need antibiotic treatment for serious infection. 

Rare

• inflammation of the testicles
• bladder contractions
• inability to pass urine.

These rare side effects can be a sign of serious infection that needs urgent antibiotic treatment.

If you experience any of these rare side effects, make a GP appointment or get in touch with us (see Contacts below).

Very rare

Make an urgent GP appointment or call 111, if you experience any of the following:

• shortness of breath
• difficulty breathing
• swelling of your face.

Follow-up

After each maintenance course of BCG, we will send you an appointment for a flexible cystoscopy.

A flexible cystoscopy is a bladder and urethra examination. It will enable us to assess how your bladder cancer has responded to your BCG treatment. We usually perform it as an outpatient procedure, in our Albany Unit.

We will schedule your flexible cystoscopy as follows:

• every 3 months during years 1 and 2
• every 6 months during years 3 and 4
• every 12 months from year 5 onwards.