Cystoscopy

Cystoscopy
Intervention
A sterile flexible cystoscope in an operating theatre
ICD-9-CM	57.31-57.33
MeSH	D003558

Cystoscopy (si-ˈstäs-kə-pē) is endoscopy of the urinary bladder via the urethra. It is carried out with a cystoscope.

Diagnostic cystoscopy is usually carried out with local anaesthesia. General anaesthesia is sometimes used for operative cystoscopic procedures.

The urethra is the tube that carries urine from the bladder to the outside of the body. The cystoscope has lenses like a telescope or microscope. These lenses let the doctor focus on the inner surfaces of the urinary tract. Some cystoscopes use optical fibres (flexible glass fibres) that carry an image from the tip of the instrument to a viewing piece at the other end. Cystoscopes range from between the thickness of a pencil, up to approximately 9mm and have a light at the tip. Many cystoscopes have extra tubes to guide other instruments for surgical procedures to treat urinary problems.

There are two main types of cystoscopy - flexible and rigid - differing in the flexibility of the cystoscope. Flexible cystoscopy is carried out with local anaesthesia on both sexes. Typically, xylocaine gel (such as the brand name Instillagel) is used as an anaesthetic, instilled in the urethra. Rigid cystoscopy can be performed under the same conditions, but is generally carried out under general anaesthesia, particularly in male subjects, due to the pain caused by the probe.

Medical uses

Cystoscopy may be recommended for any of the following conditions:^[1]

• Frequent urinary tract infections
• Blood in the urine (hematuria)
• Loss of bladder control (incontinence) or overactive bladder
• Unusual cells found in urine sample
• Need for a bladder catheter
• Painful urination, chronic pelvic pain, or interstitial cystitis
• Urinary blockage such as from prostate enlargement, stricture, or narrowing of the urinary tract
• Stone in the urinary tract
• Unusual growth, polyp, tumor, or cancer

Male and female urinary tracts

Images from a cystoscopy. The top two images show the interior of the bladder of a male patient. In the top-right image, the cystoscope has been bent within the bladder to look back on itself. The bottom two images show an inflamed urethra

If a patient has a stone lodged higher in the urinary tract, the doctor may use a much finer calibre scope called a ureteroscope through the bladder and up into the ureter. (The ureter is the tube that carries urine from the kidney to the bladder). The doctor can then see the stone and remove it with a small basket at the end of a wire which is inserted through an extra tube in the ureteroscope. For larger stones, the doctor may also use the extra tube in the ureteroscope to extend a flexible fiber that carries a laser beam to break the stone into smaller pieces that can then pass out of the body in the urine.

Test Procedures

Doctors may have special instructions, but in most cases, patients are able to eat normally and return to normal activities after the test. Patients are sometimes asked to give a urine sample before the test to check for infection. These patients should ensure that they do not urinate for a sufficient period time, such that they are able to urinate prior to this part of the test.

Patients will have to remove their clothing covering the lower part of the body, although some doctors may prefer if the patient wears a hospital gown for the examination and covers the lower part of the body with a sterile drape. In most cases, patients lie on their backs with their knees slightly parted. Occasionally, a patient may also need to have their knees raised. This is particularly when undergoing a Rigid Cystoscopy examination. For flexible cystoscopy procedures the patient is almost always alert and a local anesthetic is applied to reduce discomfort. In cases requiring a rigid cystoscopy it is not unusual for the patient to be given a general anesthetic, as these can be more uncomfortable, particularly for men. A doctor, nurse or technician will clean the area around the urethral opening and apply a local anesthetic. The local anesthetic is applied direct from a tube or needleless syringe into the urinary tract. Often, skin preparation is performed with Hibitane^[2]

Patients receiving a ureteroscopy may receive a spinal or general anaesthetic.

The doctor will gently insert the tip of the cystoscope into the urethra and slowly glide it up into the bladder. The procedure is more painful for men than for women due to the length and narrow diameter of the male urethra. Relaxing the pelvic muscles helps make this part of the test easier. A sterile liquid (water, saline, or glycine solution) will flow through the cystoscope to slowly fill the bladder and stretch it so that the doctor has a better view of the bladder wall.

As the bladder reaches capacity, patients typically feel some mild discomfort and the urge to urinate.

The time from insertion of the cystoscope to removal may be only a few minutes, or it may be longer if the doctor finds a stone and decides to remove it, or in cases where a biopsy is required. Taking a biopsy (a small tissue sample for examination under a microscope) will also make the procedure last longer. In most cases, the entire examination, including preparation, will take about 15 to 20 minutes.

Post Procedural Care and Information

After the test, patients often have some burning feeling when they urinate and often see small amounts of blood in their urine. Procedures using rigid instrumentation often result in urinary incontinence and leakage from idiopathic causes to urethral damage. Occasionally, patients may feel some lower abdominal pains, reflecting bladder muscle spasms, but these are not common.

Common (non-invasive) prescriptions to relieve discomfort after the test may include:

• Drinking 32 fluid ounces (1 L) of water over 2 hours.
• Taking a warm bath to relieve the burning feeling.
• Holding a warm, damp washcloth over the urethral opening.

Prior to the early 1990s, it was common practice for the physician performing the procedure to prescribe an antibiotic to take for a few days to prevent an infection. Since that time, many urologists will order a "Urine C & S" (urinalysis with bacterial/fungal cultures and testing for sensitivities to anti-infective medications) prior to the performance of the cystoscopy, and as part of the pre-operative workup. Depending on the results of the testing and other circumstances, he or she may elect to prescribe a 10 to 14 day course of antibiotic or other anti-infective treatment, commencing 3 days before the cystoscopy is to be performed, as this may alleviate some inflammation of the urethra prior to the procedure. This practice may provide an additional benefit by preventing an accidental infection from occurring during the procedure. The full-course of antibiotic treatment also lessens the possibility of the bacteria becoming resistant to the antibiotic/anti-infective agent prescribed.

Physicians may also prescribe an oral urinary analgesic, Phenazopyridine or a combination (urinary) analgesic/anti-infective/anti-spasmodic medication containing Methylene Blue, Methanamine, Hyoscyamine Sulfate and Phenyl Salicylate for irritation and/or dysuria patients may experience after the procedure. At two weeks post-procedure, the practitioner may order a follow-up evaluation including a repeat of the urinalysis with cultures and sensitivities, and a Uroflowmetric study (which evaluates the volume of urine released from the body, the speed with which it is released, and how long the release takes).

Notes

1. ^ Cystoscopy and Ureteroscopy - The Doctors Lounge(TM)
2. ^ http://www.rxmed.com/b.main/b2.pharmaceutical/b2.1.monographs/CPS-%20Monographs/CPS-%20(General%20Monographs-%20H)/HIBITANE.html

References

• Cystoscopy and Ureteroscopy on the National Institute of Diabetes and Digestive and Kidney Diseases website
• IMAJ Study into the Adverse Effects of Cystoscopy and its impact on patients quality of life and sexual performance (Vol 6, August 2004) http://www.ima.org.il/imaj/ar04aug-7.pdf
• An earlier version of this article was adapted from the public domain NIH Publication No. 01-4800, at http://www.niddk.nih.gov/health/kidney/pubs/cystoscopy/cystoscopy.htm which says, "This e-text is not copyrighted. The clearinghouse encourages users of this e-pub to duplicate and distribute as many copies as desired."