Cystoscopy (cystourethroscopy) is a diagnostic procedure that is used to look at the bladder (lower urinary
tract), collect urine samples, and examine the prostate gland. Performed with an optic instrument known as a cystoscope (urethroscope), this instrument uses a lighted tip for guidance to aid in diagnosing urinary tract disease and prostate disease. Performed by a urologist, this surgical test also enables biopsies to be taken or small stones to be removed by way of a hollow channel in the cystoscope.
Description
Depending on the type of information needed from a cystoscopy, the procedure typically takes 10–40 minutes to complete. The patient will be asked to urinate before surgery which allows an accurate measurement of the remaining urine in the bladder. A well lubricated cystoscope is inserted through the urethra into the bladder where a urine sample is taken. Fluid is then pushed in to inflate the bladder and allow the urologist to examine the entire bladder wall.
During an examination, the urologist may take the following steps: remove either bladder or kidney stones; gather tissue samples; and treat any suspicious lesions. In order to perform x-ray studies (retrograde pyelogram), a harmless dye is injected into the ureters by way of a catheter that is passed through the previously placed cystoscope. After completion of all needed tests, the cystoscope is removed.
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?
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 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.
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 ToKnow 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 ThePatient'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/.
Cystoscopy (cystourethroscopy) is a diagnostic procedure that is used to look at the bladder (lower urinary tract), collect urine samples, and examine the prostate gland. Performed with an optic instrument known as a cystoscope (urethroscope), this instrument uses a lighted tip for guidance to aid in diagnosing urinary tract disease and prostate disease. Performed by a urologist, this surgical test also enables biopsies to be taken or small stones to be removed by way of a hollow channel in the cystoscope.
Purpose
Categorized as an endoscopic procedure, cystoscopy is used by urologists to examine the entire bladder lining and take biopsies of any areas that look questionable. This test is not used on a routine basis but may benefit the urologist who needs further information about a patient who displays the following symptoms or diagnosis:
Blood and urine studies, in addition to x rays of the kidneys, ureters, and bladder may all occur before a cystoscopy. At the time of the procedure, a retrograde pyelogram may also be performed. Additional blood studies may be needed immediately following cystoscopy.
Precautions
While the cystoscopy procedure is commonly relied on to gather additional diagnostic information, it is an invasive surgical technique that may involve risks for certain patients. Those who are extremely overweight (obese), smoke, are recovering from a recent illness, or are treating a chronic condition may face additional risks from surgery.
Surgical risk also increases in patients who are currently using certain drugs including antihypertensives; muscle relaxants; tranquilizers; sleep inducers; insulin; sedatives; beta blockers; or cortisone. Those who use mind-altering drugs also put themselves at increased risk of complications during surgery. The following mind-altering drugs should be avoided: narcotics, psychedelics, hallucinogens, marijuana, sedatives, hypnotics, or cocaine.
Description
Depending on the type of information needed from a cystoscopy, the procedure typically takes 10–40 minutes to complete. The patient will be asked to urinate before the procedure, which allows an accurate measurement of the remaining urine in the bladder. A well-lubricated cystoscope is inserted through the urethra into the bladder, where a urine sample is taken. Fluid is then pushed in to inflate the bladder and allow the urologist to examine the entire bladder wall.
During an examination, the urologist may take the following steps: remove either bladder or kidney stones; gather tissue samples; and treat any suspicious lesions. In order to perform the x-ray studies known as a retrograde pyelogram, a harmless dye is injected into the ureters by way of a catheter that is passed through the previously placed cystoscope. After completion of all needed tests, the cystoscope is removed.
Preparation
A cystoscopic procedure can be completed in a hospital, a doctor's office, or an outpatient surgical facility. An injection of spinal or general anesthetic may be used prior to a cystoscopy. Although this test is typically performed on an outpatient basis, a patient may require up to three days' recovery in the hospital.
Aftercare
Patients who have undergone a cystoscopy will be instructed to follow these steps to ensure a quick recovery:
Because of soreness or discomfort that may occur in the urethra, especially while urinating, several warm baths a day are recommended to relieve any pain.
Allow four days for recovery.
Be aware that blood may appear in the urine. This is common and soon clears up in one to two days following the procedure.
Avoid strenuous exercise for a minimum of two weeks following cystoscopy.
Sexual relations may continue when the urologist determines that healing is complete.
Wait at least two days after surgery before driving.
Patients may also be prescribed pain relievers and antibiotics following surgery. Minor pain may also be treated with over-the-counter, nonprescription drugs such as acetaminophen.
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 also contact their physician if they experience any of the following symptoms following surgery: pain at or redness or swelling around the surgical site; drainage or bleeding from the surgical site; signs of infection, which may include headache, muscle aches, dizziness, an overall ill feeling, and fever; nausea or vomiting; strenuous or painful urination; or symptoms that may result as side effects from the medication.
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.
Questions to Ask the Doctor
Why do I need a cystoscopic examination?
How long will a cystoscopic procedure take?
How long is recovery from a cystoscopic procedure?
Abnormal Results
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, in addition to the removal of some tumors.
Resources
Periodicals
Chew, Lisa, and Stephan D. Fihn. "Recurrent cystitis in nonpregnant women." Western Journal of Medicine 170 (May 1999): 274-277.
Gilmour, D.T., P.L. Dwyer, and M.P. Carey. "Lower urinary tract injury during gynecologic surgery and its detection by intraoperative cystoscopy." Obstetrics and Gynecology 5, no. 2 (1999): 883-889.
Neumayer, Leigh, A., Mary K. Mastin, and Douglas M. Hinson. "Performance Standards: Piece of Cake or Pie in the sky?" Journal of Surgical Research 88 (2000): 47-50.
Organizations
American Cancer Society. 1599 Clifton Road, NE, Atlanta, GA 30329-4251. (800)ACS-2345. http://www.cancer.org/. The American Cancer Society (ACS) is a nationwide community-based voluntary health organization dedicated to eliminating cancer as a major health problem and is the largest source of private, nonprofit cancer funds. The ACS hopes to prevent cancer, save lives, and diminish suffering from cancer through research, education, advocacy, and service.
Interstitial Cystitis Association (ICA). 51 Monroe Street, Suite 1402, Rockville, MD 20850. 1-800-HELP-ICA. http://www.ichelp.org. Founded in 1984, the ICA is a not-for-profit health organization dedicated to providing patient and physician educational information and programs, patient support, public awareness, and research funding.
National Institute of Diabetes & Digestive & Kidney Disease. Office of Communications and Public Liaison, NIDDK, NIH, 31 Center Drive, MSC 2560, Bethesda, MD 20892-2560. NIDDK_Inquiries@nih.gov. http://www.niddk.nih.gov. Mission to understand, treat, and prevent diseases, such as diabetes and obesity, digestive diseases such as hepatitis and inflammatory bowel disease, kidney and urologic diseases such as kidney failure and prostate enlargement, and blood diseases such as the anemias.
National Kidney and Urologic Diseases Information Clearinghouse. 3 Information Way, Bethesda, MD 20892-3580. 1-800-891-5390. nkudic@info.niddk.nih.gov. http://www.niddk.nih.gov/health/kidney/nkudic.htm. Knowledge and understanding about diseases of the kidneys and urologic system among people with these conditions and their families, health care professionals, and the general public.
In rare cases, damage to internal structures may occur. Should not be done if patient has an infection of the urethra, bladder, or prostate gland.
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Other names
Cystourethroscopy.
Purpose
To detect structural abnormalities or obstructions, such as tumors or stones, inside the bladder and along the urinary tract.
How it works
Fiber-optic technology allows a doctor to actually see inside internal organs through a scope, an instrument with a flexible tube and a viewing device inserted into the urinary tract through the urethra.
Preparation
If general anesthesia is used, you will be asked to fast for eight to 12 hours before the procedure.
Your urine will be tested for signs of urinary tract infection; if found, the test will be postponed.
As you lie on your back with your knees bent, your legs spread apart, and your feet in stirrups, anesthetic jelly is injected into your urethra to numb the pain.
The physician inserts an instrument containing two separate tubes, the cystoscope and the urethroscope, into your urethra (through the penis in males) and then into the bladder. If you are unable to withstand the catheter insertion, local anesthesia with IV sedation or general anesthesia will be administered.
In order to get a better image, the physician may expand the bladder by filling it with fluid through the tube inserted into it.
During the procedure, a biopsy sample may be taken using tiny tools threaded through the catheter. Urine may also be collected through the catheter.
After the test
Your vital signs are checked, and you receive pain medication if desired.
You may be given antibiotics to prevent infection.
You should drink plenty of fluids--but no alcoholic beverages--to lessen the burning sensation you will feel when you first urinate.
Report any severe abdominal, back, or side pain; chills; fever; problems urinating; or excessive bleeding to your physician.
Factors affecting results
Failure to fast before the procedure.
Interpretation
Because the physician views the area directly through the scope, abnormalities are immediately apparent. Biopsy and urine specimens taken during the procedure are used to confirm a diagnosis.
Advantages
This is the best test for immediate detection of lesions (changes in tissue structure as a result of disease or injury) along the lower urinary tract.
Disadvantages
It involves some pain on catheter insertion.
There is an increased risk of urinary tract infection because of the trauma caused by the scope.
It requires general anesthesia.
Some patients find the procedure embarrassing.
The next step
Treatment can begin.
PATIENT TIP
Ask your doctor to use a flexible scope, which most patients find more comfortable than a rigid scope.
Examination of the bladder by means of a cystoscope, which is introduced into the urinary meatus and passed through the urethra and into the bladder. A catheter can be passed through the cystoscope into the bladder or, if necessary, beyond, into the ureters and kidneys. In this way samples of urine can be obtained for diagnostic purposes. Also, radiopaque fluids can be injected into the bladder or ureters for x-rays of the urinary tract. See also pyelography.
When a patient has a urinary problem, the doctor may use a cystoscope to see the inside of the bladder and urethra.
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 using local anaesthesia on both sexes. Typically, lidocaine/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.
A doctor may recommend cystoscopy for any of the following conditions:[1]
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 inflamedurethra
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.
After the test, patients often have some burning feeling when they urinate and often see small amounts of blood in their urine. Occasionally, patients may feel some lower abdominal pains, reflecting bladder muscle spasms, but these are not common.
Common prescriptions to relieve discomfort after the test 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.
Some doctors will prescribe an antibiotic to take for 1 or 2 days to prevent an infection. However, recent trends have been to discourage this kind of prophylactic treatment (prescribing antibiotics as a preventative when there is no other evidence of infection) because it tends to increase the rate at which bacteria develop resistance to the antibiotic drug.
Doctors may also prescribe Pyridium 200mg for irritation patients may experience after the procedure [3].
IMAJ Study into the Adverse Effects of Cystoscopy and it's impact on patients quality of life and sexual performance (Vol 6, August 2004) http://www.ima.org.il/imaj/ar04aug-7.pdf
