Cystoscopy

Definition

Cystoscopy (cystourethroscopy) is a diagnostic procedure that uses a cystoscope, which is an endoscope especially designed for urological use to examine the bladder, lower urinary tract, and prostate gland. It can also be used to collect urine samples, perform biopsies, and remove small stones.

Purpose

Cystoscopy is performed by urologists to examine the entire bladder lining and take biopsies of any questionable areas. Cystoscopy may be prescribed for patients who display the following conditions:

• blood in the urine (hematuria)
• inability to control urination (incontinence)
• urinary tract infection
• signs of congenital abnormalities in the urinary tract
• suspected tumors in the bladder
• bladder or kidney stones
• signs or symptoms of an enlarged prostate
• pain or difficulty urinating (dysuria)
• disorders of or injuries to the urinary tract
• symptoms of interstitial cystitis

Blood and urine studies, in addition to x rays of the kidneys, ureters, and bladder, may be performed before a cystoscopy to obtain as much diagnostic information as possible. During the cystoscopy, a retrograde pyelogram may also be performed to examine the kidneys and ureters.

Description

There are two types of cystoscopes used to carry out the procedure, a rigid type and a flexible type. Both types are used for the same purposes and differ only in their method of insertion. The rigid type requires that the patient adopt the lithotomy position, meaning that the patient lies on his or her back with knees up and apart. The flexible cystoscope does not require the lithotomy position.

A cystoscopy typically lasts from 10–40 minutes. The patient is asked to urinate before surgery and advised that relaxing pelvic muscles will help make this part of the procedure easier. A well-lubricated flexible or rigid cystoscope (urethroscope) is passed through the urethra into the bladder where a urine sample is taken. There may be some discomfort as the instrument is inserted. Fluid is then injected to inflate the bladder and allow the urologist to examine the entire bladder wall. The cystoscope uses a lighted tip for guidance and enables biopsies to be taken or small stones to be removed through a hollow channel in the cystoscope.

During a cystoscopy, the urologist may remove bladder stones or kidney stones, gather tissue samples, and perform x-ray studies. To remove stones, an instrument that looks like a tiny basket or grasper is inserted through the cystoscope so that small stones can be extracted through the scope's channel. For a biopsy, special forceps are inserted through the cystoscope to pinch off a tissue sample. Alternatively, a small brush-like instrument may be inserted to scrape off some tissue. To perform x-ray studies such as a retrograde pyelogram, a dye is injected into the ureter by way of a catheter passed through the cystoscope. After completion of all required tests, the cystoscope is removed.

Preparation

Patients may be asked to give a urine sample before cytoscopy to check for infection and to avoid urinating for an hour before this part of the procedure. They wear a hospital gown during the procedure and the lower part of the body is covered with a sterile drape. A sedative may be given about one hour prior to the operation to help the patient relax. The region of the urethra is cleansed and a local anesthetic is applied. Spinal or general anesthesia may also be used for the procedure. Distension of the bladder with fluid is particularly painful, and if it needs to be done, as in the case of evaluating interstitial cystitis, general anesthesia is required. A signed consent form is necessary for this procedure.

Aftercare

After removal of the cystoscope, the urethra is usually sore, and patients should expect to feel a burning sensation while urinating for one to two days following the procedure. To alleviate discomfort or pain, patients may be prescribed pain medication, and antibiotics may also be required to prevent infection. Minor pain may also be treated with over-the-counter, nonprescription drugs such as acetaminophen . To relieve discomfort, patients may be advised to drink two 8-oz glasses of water each hour for two hours and to take a warm bath to relieve the burning feeling. If not able to bathe, they may be advised to hold a warm, damp washcloth over the urethral opening.

Patients who have undergone a cystoscopy are instructed to:

• Take warm baths to relieve pain.
• Rest and refrain from driving for several days, especially if general anesthesia was used.
• Expect any blood in the urine to clear up in one to two days.
• Avoid strenuous exercise during recovery.
• Postpone sexual relations until the urologist determines that healing is complete.

Risks

As with any surgical procedure, there are some risks involved with a cystoscopy. Complications may include profuse bleeding, a damaged urethra, a perforated bladder, a urinary tract infection, or an injured penis.

Patients should contact their physician if they experience any of the following symptoms after the procedure, including pain, redness, swelling, drainage, or bleeding from the surgical site; signs of generalized infection, which may include headache, muscle aches, dizziness, or an overall ill feeling and fever; nausea or vomiting; or difficult or painful urination.

Cystoscopy is a commonly performed procedure, but it is an invasive technique that involves small yet significant risk. If anesthesia is required, there is additional risk, particularly for people who are obese, smoke, or are in poor health. Those undergoing anesthesia must inform the doctor of any medications they are taking.

Normal results

A successful cystoscopy includes a thorough examination of the bladder and collection of urine samples for cultures. If no abnormalities are seen, the results are indicated as normal. In this case, the bladder wall appears smooth and the bladder is seen to be of normal size, shape, and position, without obstructions, growths, or stones.

The treating physician can tell the patient what was seen inside the bladder right after the procedure. If a biopsy sample was taken, this will take several days to be examined and tested.

Cystoscopy allows the urologist to detect inflammation of the bladder lining, prostatic enlargement, or tumors. If these are seen, further evaluation or biopsies may be needed. Cystoscopy with bladder distention can also evaluate interstitial cystitis. Bladder stones, urethral strictures, diverticula, or congenital abnormalities can also be detected.

Alternatives

There are procedures that can provide some information about the lining of the bladder, for example, x rays; however, none of these provide as much information to the doctor as a cystoscopy.

Resources

BOOKS

Buckman, Robert. "Bladder." In What You Really Need To Know About Cancer: A Comprehensive Guide for Patients and Their Families. Baltimore, MD: The Johns Hopkins University Press, 1997.

Miller, B. E., ed. An Atlas of Sigmoidoscopy and Cystoscopy. Boca Raton: CRC Press-Parthenon Publishers, 2001.

Segen, Joseph C., and Joseph Stauffer. "Cystoscopy." In The Patient's Guide To Medical Tests: Everything You Need To Know About The Tests Your Doctor Prescribes. New York: Facts On File, 1998.

Tierney, Lawrence M. Jr., Stephen J. McPhee, and Maxine A. Papadakis, eds. "Urology." In Current Medical Diagnosis and Treatment. Stamford, CT: Appleton & Lange, 1996.

PERIODICALS

Fraczyk, L., H. Godfrey, and R. Feneley. "Flexible Cystoscopy: Outpatients or Domiciliary?" British Journal of Community Nursing 7 (February 2002): 69–74.

Jabs, C. F., and H. P. Drutz. "The Role of Intraoperative Cystoscopy in Prolapse and Incontinence Surgery." American Journal of Obstetrics and Gynecology 185 (December 2001): 1368–1371.

Kwon, C. H., R. Goldberg, S. Koduri, and P. K. Sand. "The Use of Intraoperative Cystoscopy in Major Vaginal and Urogynecologic Surgeries." American Journal of Obstetrics and Gynecology 187 (December 2002): 1471–1472.

Payne, D. A., and R. C. Kockelbergh. "Improving the View at Flexible Cystoscopy." Annals of The Royal College of Surgeons of England 85 (March 2003): 132–138.

Sant, Grannum R., and Philip M. Hanno. "Interstitial Cystitis: Current Issues and Controversies in Diagnosis." Urology 57, Supplement 6A (June 2001): 82–88.

Satoh, E., N. Miyao, H. Tachiki, and Y. Fujisawa. "Prediction of Muscle Invasion of Bladder Cancer by Cystoscopy." European Urology 41 (February 2002): 178–181.

ORGANIZATIONS

American Urological Association. 1120 North Charles Street, Baltimore, MD 21201. (410) 727-1100. http://www.auanet.org .

American Foundation for Urologic Disease. 1128 North Charles Street, Baltimore, MD 21201. (800) 242-2383. http://www.afud.org .

Interstitial Cystitis Association. 51 Monroe Street, Suite 1402, Rockville, MD 20850. (301) 610-5300. http://www.ichelp.org .

Society of Urologic Nurses and Associates. East Holly Avenue, Box 56, Pitman, NJ 08071-0056. (609) 256-2335. http://suna.inurse.com/ .

OTHER

"Cystoscopy." Harvard Medical School. <www.health.harvard.edu/fhg/diagnostics/cysto/cystoWhat.shtml� 3E; .

"Cystoscopy." Medline Plus. http://www.nlm.nih.gov/medline plus/ency/article/003903.htm .

"What Is IC? Interstitial Cystitis Fact Sheet." Interstitial Cystitis Association. http://www.ichelp.org/whatisic/ICFAct Sheet.html .

Jennifer E. Sisk Monique Laberge, PhD

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Cystoscopy is typically performed on an outpatient basis, but up to three days of recovery in the hospital is sometimes required. The procedure can be performed in a hospital, doctor's office, cystoscopy suite, or urology office, depending on the condition of the patient and the anesthesia required. If general anesthesia is required, an anesthesiologist is present to administer the anesthesia and monitor the patient. The cystoscopy procedure is performed by a urologist, urologic surgeon, or urogynecologist, with assistance from nurses experienced in urologic procedures. If x rays are taken during the procedure, a uroradiologist or radiologic technologist is required to operate the x-ray equipment. Biopsy tissue samples are sent to the clinical laboratory for examination by a pathologist.

QUESTIONS TO ASK THE DOCTOR

• What will happen during the procedure?
• How do I prepare for cytoscopy?
• Will cystoscopy hurt?
• How long will the test last?
• How many cytoscopies do you perform each year?
• Are there any risks associated with the procedure?