Cystoscopy

A sterile flexible cystoscope in an operating theatre

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

• urinary tract infections;
• blood in the urine (hematuria);
• loss of bladder control (incontinence) or overactive bladder; (Although, the American Urogynecologic Society does not recommend that cystoscopy, urodynamics, or diagnostic renal and bladder ultrasound are part of initial diagnosis for uncomplicated overactive bladder.)[2][3]
• 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; and
• unusual growth, polyp, tumor, or cancer.

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 physician 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 physician can then see the stone and remove it with a small basket at the end of a wire that is inserted through an extra tube in the ureteroscope. For larger stones, the physician 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.

Physicians 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 of 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 physicians 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 his or her knees raised. This is particularly true 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 physician, 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 chlorhexidine.[4]

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

The physician 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 physician 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 physician 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.

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; and
• 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).

Cystoscopy has similar indications in animals, including visualisation and biopsy of mucosa, retrieval or destruction of urinary bladder stones and diagnosis of ectopic ureters.[7][8][9]

In turtle and tortoises, cystoscopy has additional value as it permits the visualisation of internal organs due to the thin urinary bladder wall.[10] In young individuals in which sex determination would not be feasible by visualisation of external morphologic features, this technique permits noninvasive visualisation of gonads, and therefore sex determination.[11]

• An earlier version of this article was adapted from the public domain NIH Publication No. 01-4800, 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."

• Cystoscopy and Ureteroscopy on the National Institute of Diabetes and Digestive and Kidney Diseases website