What is flexible cystoscopy. How is the procedure performed. What are the common indications for flexible cystoscopy. What are the potential complications and side effects. How long does recovery typically take after flexible cystoscopy. When should patients seek medical attention following the procedure.

Understanding Flexible Cystoscopy: A Modern Diagnostic Tool

Flexible cystoscopy is a revolutionary diagnostic procedure in urology that has transformed the way bladder and urethral conditions are examined. This minimally invasive technique, which utilizes a flexible fiberscope, has been in regular use since the early 1980s. But what exactly is flexible cystoscopy, and how does it differ from traditional rigid cystoscopy?

Flexible cystoscopy involves the insertion of a thin, flexible tube equipped with a camera and light source through the urethra and into the bladder. This procedure is typically performed under local anesthesia in an outpatient setting, making it more comfortable for patients compared to rigid cystoscopy, which often requires general or spinal anesthesia.

The Evolution of Cystoscopy

The journey towards flexible cystoscopy began in 1964 when Marshall first suggested the use of a fiberscope for urethrocystoscopy. However, it wasn’t until 1973 that Tsuchida and Sugawara first applied this technology in urology to examine the bladder neck. The regular use of fiberscopes in urology started to gain traction in the early 1980s, marking a significant advancement in diagnostic capabilities.

Indications for Flexible Cystoscopy: When Is It Recommended?

Flexible cystoscopy is recommended for a variety of urological conditions and symptoms. But what are the most common reasons a doctor might order this procedure?

• Evaluation of hematuria (blood in urine)
• Investigation of recurrent urinary tract infections
• Assessment of lower urinary tract symptoms
• Surveillance of bladder cancer
• Diagnosis of urethral strictures
• Identification of bladder stones
• Evaluation of prostate enlargement effects on the bladder

These indications cover a wide range of urological concerns, demonstrating the versatility and importance of flexible cystoscopy in modern urology practice.

The Procedure: What to Expect During a Flexible Cystoscopy

Understanding the procedure can help alleviate anxiety for patients scheduled to undergo flexible cystoscopy. So, what happens during the procedure?

1. The patient is positioned on an examination table, usually lying on their back.
2. A local anesthetic gel is applied to the urethra to minimize discomfort.
3. The flexible cystoscope is gently inserted through the urethra and into the bladder.
4. Sterile water is used to fill the bladder, allowing for better visualization.
5. The urologist examines the urethra and bladder, looking for any abnormalities.
6. The procedure typically takes 5-10 minutes to complete.

Throughout the procedure, patients may feel a sensation of fullness in the bladder and a mild urge to urinate, but severe pain is uncommon.

Recovery After Flexible Cystoscopy: What Patients Need to Know

Recovery following a flexible cystoscopy is generally quick and straightforward. How soon can patients return to their normal activities?

After a flexible cystoscopy, most patients can return home shortly after the procedure, once they’ve emptied their bladder. There’s usually no need to wait for the local anesthetic to wear off completely. Many individuals can resume their normal activities, including work and exercise, later the same day or the following day.

Common Post-Procedure Effects

It’s normal to experience some mild side effects after a flexible cystoscopy. These may include:

• A burning or stinging sensation when urinating
• Slight blood in the urine, which may turn it pink
• Increased frequency of urination

These effects typically subside within a day or two. Drinking plenty of water can help alleviate these symptoms, and over-the-counter pain relievers like paracetamol can be used to manage any discomfort.

Potential Complications: When to Seek Medical Attention

While flexible cystoscopy is generally safe, it’s important for patients to be aware of potential complications. When should patients contact their healthcare provider after the procedure?

Patients should seek medical advice if they experience:

• Pain or bleeding lasting more than a few days
• Severe pain during urination
• Urine that is extremely bloody or contains blood clots
• Inability to empty the bladder
• Foul-smelling urine
• High fever
• Nausea or vomiting
• Pain in the lower back or side

These symptoms could indicate complications such as infection or injury and require prompt medical attention. In severe cases, patients should go to the nearest emergency department.

Advantages of Flexible Cystoscopy over Rigid Cystoscopy

Flexible cystoscopy offers several advantages over its rigid counterpart. But what makes it the preferred choice in many situations?

• Increased patient comfort: The flexible scope can navigate the natural curves of the urethra more easily.
• Local anesthesia: Most flexible cystoscopies can be performed under local anesthesia, reducing risks associated with general anesthesia.
• Outpatient procedure: Patients can typically go home shortly after the procedure.
• Quicker recovery: Return to normal activities is usually possible within a day.
• Better visualization: The flexible scope can reach areas that might be difficult to see with a rigid scope.

These advantages have contributed to the widespread adoption of flexible cystoscopy in urological practice.

Limitations of Flexible Cystoscopy: Understanding Its Constraints

Despite its many benefits, flexible cystoscopy does have some limitations. What are the scenarios where it might not be the best option?

The main limitation of flexible cystoscopy is in cases of heavy bleeding. In such situations, it can be difficult to identify important structures like the ureteric orifices. Additionally, the image quality of flexible scopes, while constantly improving, may not always match that of rigid scopes in some cases.

Furthermore, certain therapeutic procedures, such as large tumor resections or stone removals, still require rigid cystoscopy due to the need for larger instruments and better irrigation flow.

Future Developments in Flexible Cystoscopy Technology

The field of flexible cystoscopy continues to evolve. What advancements can we expect in the future?

Ongoing research and development in flexible cystoscopy technology are focused on several areas:

• Improved image quality: High-definition and 4K imaging systems are being developed to enhance visualization.
• Enhanced flexibility: More maneuverable scopes are being designed to improve access to difficult-to-reach areas.
• Integration with other technologies: Combining flexible cystoscopy with techniques like narrow-band imaging or photodynamic diagnosis to improve detection of subtle lesions.
• Miniaturization: Development of even smaller scopes to further reduce patient discomfort.
• Disposable scopes: Single-use flexible cystoscopes are being introduced to eliminate the risk of cross-contamination and reduce maintenance costs.

These advancements promise to further improve the diagnostic capabilities and patient experience of flexible cystoscopy procedures.

Flexible cystoscopy has revolutionized urological diagnostics, offering a less invasive and more comfortable option for patients. Its ability to provide detailed visualization of the lower urinary tract while minimizing patient discomfort has made it an invaluable tool in modern urology practice. As technology continues to advance, we can expect flexible cystoscopy to become even more effective and patient-friendly, further cementing its role as a cornerstone of urological diagnosis and management.

Cystoscopy – Recovery – NHS

You should be able to get back to normal quite quickly after a cystoscopy.

How long it takes to recover depends if you had a flexible cystoscopy (using local anaesthetic gel) or a rigid cystoscopy (under general anaesthetic or spinal anaesthetic).

Going home

After a flexible cystoscopy

You’ll be able to go home shortly after a flexible cystoscopy, once you’ve emptied your bladder.

There’s usually no need to wait in the hospital until the anaesthetic has completely worn off.

After a rigid cystoscopy

If you have a rigid cystoscopy, you’ll probably need to stay in hospital for a few hours until the anaesthetic starts to wear off.

You can go home once you’re feeling better and you’ve emptied your bladder. Most people leave hospital the same day, but sometimes an overnight stay might be needed.

You’ll need to arrange for someone to take you home as you will not be able to drive for at least 24 hours.

Getting back to normal

After a flexible cystoscopy

You can return to your normal activities – including work, exercise and having sex – as soon as you feel able to after a flexible cystoscopy.

This will often be later the same day or possibly the day after.

After a rigid cystoscopy

After a rigid cystoscopy:

• rest at home for a day or two – you may need to take a couple of days off work
• make sure someone stays with you for the first 24 hours
• do not drive or drink alcohol for at least 24 hours

You can usually return to your normal activities – including work, exercise and having sex – when you feel able to.

After effects of a cystoscopy

After a cystoscopy, it’s normal to have:

• a burning or stinging sensation when peeing
• some blood in your pee, which may turn it slightly pink
• a need to pee more often than usual

These side effects should pass after a day or two.

Drinking plenty of water during the first few days can help. You can also take painkillers such as paracetamol to reduce any discomfort.

When to get medical advice

Contact a GP for advice if:

• the pain or bleeding lasts more than a few days
• peeing is very painful
• your pee becomes so bloody that you cannot see through it
• you see red lumps (blood clots) in your pee
• you cannot empty your bladder
• your pee smells bad
• you get a high temperature
• you feel sick or vomit
• you have pain in your lower back or side

Go to your nearest accident and emergency (A&E) department if you feel really unwell.

These problems could be caused by complications of a cystoscopy, such as an infection.

Page last reviewed: 20 April 2020
Next review due: 20 April 2023

ABC of flexible cystoscopy for junior trainee and general practitioner

Int J Gen Med. 2011; 4: 593–596.

Published online 2011 Aug 19. doi: 10.2147/IJGM.S20267

Author information Article notes Copyright and License information Disclaimer

Introduction:

Flexible cystoscopy is a diagnostic procedure usually performed under local anesthesia and has been used in the outpatient setting since the 1980s.

Methods:

We performed an electronic search of MEDLINE^® and the Cochrane Central Search Library between 1990 and 2010. Duplicate references were removed. One reviewer extracted the publications relevant to general clinical practice.

Results:

MEDLINE search using the MeSH (Medical Subject Headings) words “flexible” and “cystoscopy” revealed 274 titles, and there were 42 titles in the Cochrane Central Search Library. However, interestingly, only 13 published papers addressing the clinical practice of flexible cystoscopy in the English literature were identified.

Conclusions:

Flexible cystoscopy is a real revolution in the field of diagnostic urology.

Keywords: clinical practice, urology, fiberscope, urethrocystoscopy

The early suggestion of use of fiberscope urethrocystoscopy was by Marshall in 1964.¹ The first use of the fiberscope in urology was by Tsuchida and Sugawara in 1973² to examine the bladder neck.^3–5 Nevertheless, the regular use of the fiberscope in urology was in the first few years of the 1980s.^6,7

Few authors thought at the time that the fiberscope would replace the rigid scope; however, we should mention that the fiberscope has its limitations, especially in heavy bleeding, as it is usually not possible to identify the ureteric orifices.^8,9

We performed an electronic search of MEDLINE^® and the Cochrane Central Search Library between 1990 and 2010. We retrieved citations using combinations of the search term “flexible” and “cystoscopy.” For MEDLINE, we limited the search to the English language, using the limits function.

The search was done in the Cochrane Central Search Library using “flexible cystoscopy.” Duplicate references were removed.

One reviewer (NK) extracted from these data the relevant publications to clinical practice. Data were characterized in the following categories: indication, procedure, complications, and the need for prophylaxis antibiotic before flexible cystoscopy.

The MEDLINE search between 1990 and 2010 with limited search to the English language revealed 274 titles, while the Cochrane Central Search Library search for “flexible cystoscopy” revealed 42 results.

Interestingly, only 13 articles were directly relevant to clinical practice. From these articles, there was one prospective randomized study regarding instillation of anesthetic gel necessary in flexible cystoscopy examination, one randomized double-blind controlled trial regarding the need of prophylaxis antibiotic for flexible cystoscopy, and one meta-analysis of prospective randomized controlled trials regarding the use of local anesthetic gel versus plain lubricating gel for pain reduction during flexible cystoscopy. The main relevant articles are shown in .

Table 1

The main relevant articles

Open in a separate window

Interestingly, the search of the recent published literature revealed few articles that address the clinical practice of flexible cystoscopy. We categorized the data into the following categories.

The common indication of flexible cystoscopy

Flexible cystoscopy is used mainly to investigate patients presenting with microscopic hematuria and frank hematuria, recurrent urinary tract infections, irritative lower urinary tract symptoms, and for follow up (surveillance) of bladder tumors.¹¹

Other indications for flexible cystoscopy include removal of JJ ureteric stents and insertion of urethral catheter over a guidewire (in cases of difficult urethral catheterization). Flexible cystoscopy can also be used to get bladder biopsies and to treat small low-grade superficial bladder cancers using diathermy (cystodiathermy).

More recently, flexible cystoscopy has been used for intradetrusor injection of botulinum toxin under local anesthetic. However, the commonest indication for flexible cystoscopy remains its role in the follow up (surveillance) of bladder tumors.^11–14

Procedure

Flexible cystoscopy should be carried out after obtaining informed consent; we recommend using the British Association of Urological Surgeons consent form. ¹⁵ The published literature also recommend a urinalysis before the procedure to exclude active urinary tract infection, which is a relative contraindication because of the small risk of septicemia.^16,17

Following preparation of the genitalia using antiseptic solution, the area is covered with sterile drapes. Local anesthetic is slowly instilled into the male urethra; female urethra simply requires lubrication.^18,19

The scope is then gently advanced through the urethra in aseptic technique. The urethra is inspected along its length for any abnormalities such as strictures (narrowing), false passages, and growths. The bladder is then filled with sterile liquid (water, saline, or glycine solution) until the mucosal folds open up. The bladder is then carefully inspected in a systematic manner. This involves inspection of all the walls of the bladder, as well as both ureteric orifices. The bladder neck is examined by performing the J maneuver with the scope. Once the inspection has been fully carried out, the scope is gently withdrawn to examine the urethra on the way out as well.

Complications

Flexible cystoscopy is generally considered safe. The complications include pain on voiding (dysuria) (50%), hematuria (19%), and frequency (37%), all of which are usually self-limiting. The risk of urinary tract infection post flexible cystoscopy is approximately 2.7%.¹⁷

To reduce the potential severe complications after flexible cystoscopy, patients are advised to increase their fluid intake post-procedure and to seek medical help if they feel unwell with increasing pain on voiding (dysuria), rigors, or fever.

Do we need prophylaxis antibiotic before flexible cystoscopy?

The use of prophylaxis antibiotic before flexible cystoscopy is very controversial.^20–22 In the UK, there is no guideline for the use of prophylactic antibiotic before flexible cystoscopy, and each hospital follows its own protocol. There is not enough evidence to support the routine use of prophylactic antibiotic before flexible cystoscopy; however, it should be considered in immunocompromised patients or those with suspected urinary tract infections.

NICE (National Institute for Health and Clinical Excellence) guidelines no longer recommend the routine use of prophylactic antibiotic for patients with artificial heart valves.²³ If prophylaxis is used, the choice, route of administration, and duration of use of antibiotic should be based on local microbiological advice.

Flexible cystoscopy can be done under local anesthesia in the outpatient setting, and thus it has revolutionized the field of diagnostic urology procedures.

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Cystoscopy. (A) Female. (B) Male.

Disclosure

The authors report no conflicts of interest in this work.

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what it is, preparation, how it is done, contraindications – health articles

Urethrocystoscopy, or cystourethroscopy, is an endoscopic examination, that is, a visual examination of the walls of the urethra, bladder and ureter outlets using optics in order to detect pathology. It is a diagnostic procedure, however, it makes it possible for targeted sampling of biomaterial (simultaneous biopsy) when pathological foci are detected and drugs are administered.

The study allows not only to examine the bladder cavity, but also to evaluate the functions of each kidney separately by the nature of the ureter discharged from the right and left mouths, since they open into the bladder and are well visualized during the procedure. It can be used as an auxiliary method for diagnosing prostate adenoma – medical indications for cystoscopy are quite wide.

When is it held?

The procedure can be prescribed at any age and is the main diagnostic method for many diseases of the genitourinary system, when safer research methods (ultrasound, radiation, magnetic resonance) do not provide the necessary information. If stones are found, they can be removed using special forceps or electroresection, and the neoplasms are sent for histological examination.

In the presence of ulcerative lesions of the mucosa, electrocoagulation (cauterization) of the damaged areas can be done.

In case of tumors and inflammatory diseases of the prostate, cystoscopy in men will help determine the degree and nature of the involvement of the bladder and urethra in the pathological process.

Indications:

• Cystitis and urethritis: pain, burning and cutting when urinating, pain in the lumbosacral spine, frequent urination with small portions of urine
• Tumors of the bladder: symptoms similar to cystitis, but atypical cells were found on a swab from the urethra or urine
• Prostatitis, prostate adenoma: frequent urge to urinate, sensation of incomplete emptying of the bladder, incontinence/urinary retention, nocturia (frequent nighttime urge to go to the toilet)
• Sexual disorders in men (male infertility): to assess the condition of the seminal tubercle
• Suspicion of urolithiasis with localization of stones in the bladder: pain and cramps in the lower abdomen, difficult painful urination in small portions, a feeling of insufficient emptying of the bladder, turbidity of the urine to a whitish hue, the appearance of salt crystals in the urine (crystalluria)
• Enuresis – bedwetting (urination occurs during sleep) in the absence of mental and neurological pathologies
• Pyuria – excretion of pus with urine (appearance of foreign light clots in the liquid, turbidity)
• Hematuria – blood impurities in the urine (discoloration and transparency of the liquid, the appearance of blood clots) in the absence of injuries
• Anomalies of the genitourinary system or suspicion of them – to assess the volume and shape of the reservoir and urinary tract
• Evaluation of the effectiveness of treatment

Contraindications

Contraindications mean that cystoscopy in these cases is indicated only when other methods are not informative.

• Acute inflammatory processes in the bladder (acute cystitis), urethra (acute urethritis), prostate (acute prostatitis), testicles (acute orchitis) – in men, in the uterus and appendages – in women, during fever
• Bleeding from the urethra of unknown etiology
• Injuries of the urethra and bladder
• Disorders in the hemostasis system (hemophilia)

Cystoscopy

Despite the fact that cystoscopy is a diagnostic procedure, with its help, as with the help of almost all endoscopic examinations, some therapeutic manipulations can be performed:

• Crushing and removal of small stones
• Removal of polyps, small tumors with their further examination with simultaneous coagulation of wound surfaces
• Coagulation of erosions and ulcers of the urethra, bladder
• Removal of clots or foreign bodies and restoration of the patency of the urinary tract when obstructed by blood, pus or small stones
• Injection of medicinal solutions, bladder and urethral lavage (lavage water is also collected for examination)

How to prepare?

Cystoscopy under anesthesia requires early (10-12 hours) refusal of food and fluids (3-4 hours), after the procedure it will take time to recover, therefore it is not recommended to use personal transport and engage in potentially dangerous activities that require concentration attention.

Cystoscopy without anesthesia does not require any special preparation: it is enough to arrive on an empty stomach, having performed the toilet of the genitals before leaving the house. Before the procedure, you should empty your bladder.

The choice of the type of anesthesia will depend on the indications: cystoscopy under anesthesia or “in a dream” is indicated for excitable or mentally unbalanced patients. Anesthesia can be both general and spinal (only the lower half of the body loses sensitivity, from the lower back, consciousness is preserved).

Since the structure of the male urethra is somewhat more complex (it can be 6 times longer than the female), spinal or general anesthesia is more often recommended for cystoscopy in men to eliminate pain. Also, anesthesia can be recommended if a long examination is expected, removal of multiple neoplasms, if the bladder of the subject has a small (150 ml or less) capacity.

How is the procedure?

• Before the start of the diagnosis, the subject is given a sterile gown, he is asked to undress and lie on the couch on his back, bending his knees, they explain how the examination will take place and what sensations will arise during this
• The external genitalia are treated with antiseptic solutions, the endoscope is lubricated with glycerin to improve glide. For men, an anesthetic is injected into the urethra using a syringe with a rubber tube and a clamp, held until the analgesic effect begins (about 10 minutes)

The technique of the procedure will vary depending on the type of instrument. There are rigid and flexible endoscopy.

• Rigid bladder endoscopy is performed using a rigid endoscope on a long (30 cm) metal tube. Such an endoscope spreads tissues well, simplifying examination, however, it is more traumatic and causes more discomfort to the examinee, especially men. A rigid endoscope is not used in the presence of large tumors of the pelvic organs, pregnancy. During hard cystoscopy, an endoscope tube is inserted into the urethra and fluid is supplied to the bladder, which simultaneously flushes it and straightens the mucosal folds, improving visualization. To supply and drain liquid, a two-way valve is connected to the endoscope tube, since if there is pus or blood in the cavity that cloud the environment, the organ must be cleaned before examination. Wash water is collected for analysis
• Flexible endoscopy uses a flexible endoscope, a movable thin tube made of polymer material with an optic and a lamp at the end. The device repeats the curves of the body and therefore can easily penetrate into hard-to-reach places, which makes the examination quite informative. This method allows minimizing injuries and nullifying pain during the procedure. In modern diagnostics, flexible cystoscopy is gradually replacing rigid

Cystoscopy for different patients

Cystoscopy of the bladder in women. As a rule, cystoscopy in women does not cause difficulties and does not require general anesthesia, since the female urethra is straight and short (up to 5 cm). For anesthesia, a local anesthetic is applied to the endoscope tube. Difficulties arise in the presence of large uterine tumors or in late pregnancy, when the uterus compresses the bladder and changes its configuration. In this case, the use of flexible endoscopy is indicated. Examination during pregnancy is performed only for health reasons, since any intervention on the pelvic organs can provoke a spontaneous abortion.

Bladder cystoscopy in men. The male urethra is 17 to 22 cm long, so the examination requires special care and experience from the endoscopist, especially at the stage of inserting the instrument. During the procedure, an anesthesiologist must be constantly in the operating room, who can anesthetize the patient if he experiences severe pain during the study.

For children, bladder cystoscopy is performed only with a flexible pediatric endoscope, which is much thinner than an adult, and only by an experienced pediatric diagnostician.

Consequences of the procedure

After the cessation of the anesthetic effect, patients, as a rule, experience slight discomfort and burning in the urinary tract, aggravated by urination (especially after cystoscopy in men), frequent urination. After using a rigid endoscope, light pink mucus may be discharged. To reduce pain, it is recommended to increase the amount of fluid consumed (which, in turn, will reduce the concentration of urine), apply an anesthetic once.

If the symptoms do not go away within three days or they are accompanied by fresh blood discharge, chills, fever, you must immediately return to the clinic or call a doctor.

Advantages of the procedure in MEDSI:

• With a high reputation of the doctors of the clinic, the price of cystoscopy is at the level of the average cost of a service in private clinics in Moscow
• Territorial accessibility
• Opportunity to conduct an examination and get expert advice before and after the procedure in the same branch
• Prevention and control of complications, hospitalization in the clinic at will or according to indications
• Experienced diagnosticians with extensive experience, availability of pediatric specialists
• Discreet staff, technical and courteous service

To make an appointment, call the round-the-clock phone number +7 (495) 7-800-500.

Do not delay treatment, see a doctor now:

• Cystoscopy
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Endoscopic method of bladder diagnostics in Nearmedic Obninsk

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• Endoscopy of the bladder

Flexible Cystoscopy is a procedure performed using a special optical instrument called a cystoscope. A cystoscope is a long tube that is equipped with a light source and a video camera. The cystoscope allows you to see the internal structure of the urethra and bladder. With the help of cystoscopy, you can get a large amount of information that is not available with X-ray and ultrasound. For whom is cystoscopy performed with a flexible cystoscope?

Due to the anatomical structure of the male urethra, cystoscopy in men is a much more technically complex and painful procedure. The use of a flexible cystoscope can significantly reduce the pain and discomfort that occurs during the procedure and reduce the incidence of cystoscopy complications by several times.
What is the advantage of the method?

Flexible cystoscopy allows you to view the cavity of the urethra and bladder. In the diagnosis of diseases of the mucous membrane of the urethra and bladder, the method is much more sensitive and specific.

Under what conditions is urethrocystoscopy indicated?

• interstitial cystitis
• bladder stones
• urinary incontinence / overactive bladder
• Bladder tumor
• blood in the urine (hematuria)
• for ureteral catheterization
• urethral stricture
• chronic cystitis

What are the contraindications for cystoscopy?

• fresh urinary tract infection
• fresh trauma of the urethra
• urethral obstruction

How is a cystoscopy performed?

Cystoscopy can be performed on an inpatient or outpatient basis.