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Cystoscopy

  • Author: Gamal Mostafa Ghoniem, MD, FACS; Chief Editor: Edward David Kim, MD, FACS  more...
 
Updated: Jan 05, 2016
 

Background

Cystoscopy is endoscopy of the urinary bladder via the urethra. It may employ either a rigid or a flexible cystoscope and may be performed for either diagnostic or therapeutic purposes.

The first instrument used for visualizing the body from inside was developed by Philipp Bozzini (1773-1809), a German army surgeon, who invented the Lichtleiter (the ancestor of modern endoscopes) in 1807. Bozzini used this innovation for viewing the bullets in his patients.[1] The cystourethroscope has been greatly improved by the introduction of cold light, the enhancement of the optical system, and the development of videoendoscopy, flexible instruments, and virtual endoscopy.[2, 3]

Relevant Anatomy

The adult bladder is located in the anterior pelvis and is enveloped by extraperitoneal fat and connective tissue. It is separated from the pubic symphysis by an anterior prevesical space known as the retropubic space (of Retzius). The dome of the bladder is covered by peritoneum, and the bladder neck is fixed to neighboring structures by reflections of the pelvic fascia and by true ligaments of the pelvis.

The body of the bladder receives support from the external urethral sphincter muscle and the perineal membrane inferiorly and the obturator internus muscles laterally (see the image below).

Gross anatomy of the bladder. Gross anatomy of the bladder.

For more information about the relevant anatomy, see Bladder Anatomy. See also Female Urethra Anatomy, Female Urinary Organ Anatomy, Male Urethra Anatomy, and Male Urinary Organ Anatomy.

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Indications and Contraindications

Diagnostic indications for cystoscopy include the following:

  • Evaluation of patients with voiding symptoms (storage or obstructive)
  • Gross or microscopic hematuria
  • Evaluation of urologic fistulas
  • Evaluation of urethral or bladder diverticula
  • Congenital anomilies in pediatric population
  • Retrieval of samples (for cytologic and histologic studies)
  • Intraoperative evaluation of the urethra, bladder, and ureters after some incontinence or prolapse procedures
  • Retrograde pyelography for upper urinary tract evaluation

Therapeutic indications include the following:

  • Treatment of urethral strictures
  • Bladder neck procedures [4]
  • Intravesical procedures (eg, for treatment of bladder stones, bladder ulcers, or bladder tumors; removal of foreign bodies in the bladder; botulinum toxin injection; and ureteral catheterization in association with some gynecologic problems)
  • Reflux treatment in pediatric population

Cystourethroscopy is contraindicated in febrile patients with urinary tract infections (UTIs) and those with severe coagulopathy.

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Technical Considerations

There is level Ib, III, and IV evidence to suggest that antibiotic prophylaxis before simple cystourethroscopy should be administered only in the presence of risk factors for UTI, such as advanced age, anatomic anomalies of the urinary tract, poor nutritional status, smoking, long-term corticosteroid use, immunodeficiency, fixed catheters, coexisting infection, and prolonged hospitalization.

For those who have any of these risk factors, the recommended antibiotic prophylaxis includes a single dose of either a fluoroquinolone or trimethoprim-sulfamethoxazole. Alternatively, an aminoglycoside (with or without ampicillin), a first- or second-generation cephalosporin, or amoxicillin-clavulanate may be given. Patients with negative urine cultures and those without any of these risk factors do not need antibiotic prophylaxis before cystourethroscopy.

The above recommendations hold true for simple cystourethroscopy; however, all patients who are scheduled to undergo cystourethroscopy with manipulations should receive antibiotic prophylaxis.[5] According to the American Heart Association (AHA), antimicrobials are no longer recommended solely to prevent infectious endocarditis in association with genitourinary procedures.[6]

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Contributor Information and Disclosures
Author

Gamal Mostafa Ghoniem, MD, FACS Professor and Vice Chair of Urology, Chief, Division of Female Urology, Pelvic Reconstructive Surgery, and Voiding Dysfunction, Department of Urology, University of California, Irvine, School of Medicine

Gamal Mostafa Ghoniem, MD, FACS is a member of the following medical societies: American Urogynecologic Society, International Continence Society, International Urogynaecology Association, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction, American College of Surgeons, American Urological Association

Disclosure: Received honoraria from Astellas for speaking and teaching; Received grant/research funds from Uroplasty for none; Partner received honoraria from Allergan for speaking and teaching.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

Acknowledgements

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Acknowledgments

Medscape Reference thanks Michel Rivlin, MD, G Rodney Meeks, MD, Dennis G Lusaya, MD, and Edgar V Lerma, MD, for assistance with the video contribution to this article.

References
  1. Choe JH, Kwak KW, Hong JH, Lee HM. Efficacy of lidocaine spray as topical anesthesia for outpatient rigid cystoscopy in women: a prospective, randomized, double-blind trial. Urology. 2008 Apr. 71(4):561-6. [Medline].

  2. Karabacak OR, Cakmakci E, Ozturk U, Demirel F, Dilli A, Hekimoglu B, et al. Virtual cystoscopy: the evaluation of bladder lesions with computed tomographic virtual cystoscopy. Can Urol Assoc J. 2011 Feb. 5(1):34-7. [Medline]. [Full Text].

  3. Kuehhas FE, Weibl P, Tosev G, Schatzl G, Heinz-Peer G. Multidetector computed tomography virtual cystoscopy: an effective diagnostic tool in patients with hematuria. Urology. 2012 Feb. 79(2):270-6. [Medline].

  4. Dimon M, Williams C. Continuous Retroflexion Cystoscopy During Prostate Cryoablation. J Endourol. 2012 Jan 4. [Medline].

  5. Wolf JS Jr, Bennett CJ, Dmochowski RR, Hollenbeck BK, Pearle MS, Schaeffer AJ. Best practice policy statement on urologic surgery antimicrobial prophylaxis. J Urol. 2008 Apr. 179(4):1379-90. [Medline].

  6. Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007 Oct 9. 116(15):1736-54. [Medline].

  7. Zhang ZS, Tang L, Wang XL, Xu CL, Sun YH. Seeing Is Believing: A Randomized Controlled Study from China of Real-Time Visualization of Flexible Cystoscopy to Improve Male Patient Comfort. J Endourol. 2011 Jul 11. [Medline].

  8. Cano-Garcia Mdel C, Casares-Perez R, Arrabal-Martin M, Merino-Salas S, Arrabal-Polo MA. Use of Lidocaine 2% Gel Does Not Reduce Pain during Flexible Cystoscopy and Is Not Cost-Effective. Urol J. 2015 Nov 14. 12 (5):2362-5. [Medline].

  9. Patel AR, Jones JS, Babineau D. Lidocaine 2% gel versus plain lubricating gel for pain reduction during flexible cystoscopy: a meta-analysis of prospective, randomized, controlled trials. J Urol. 2008 Mar. 179 (3):986-90. [Medline].

  10. Rodríguez-Rubio F, Sanz G, Garrido S, Sánchez C, Estudillo F. Patient tolerance during outpatient flexible cystoscopy--a prospective, randomized, double-blind study comparing plain lubrication and lidocaine gel. Scand J Urol Nephrol. 2004. 38(6):477-80. [Medline].

  11. Clark KR, Higgs MJ. Urinary infection following out-patient flexible cystoscopy. Br J Urol. 1990 Nov. 66(5):503-5. [Medline].

  12. Seklehner S, Remzi M, Fajkovic H, Saratlija-Novakovic Z, Skopek M, Resch I, et al. Prospective multi-institutional study analyzing pain perception of flexible and rigid cystoscopy in men. Urology. 2015 Apr. 85 (4):737-41. [Medline].

 
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Rigid cystoscope with connections to irrigation and light source.
Flexible cystoscope.
Bladder distention in patient with interstitial cystitis.
Large supratrigonal vesicovaginal fistula, showing tip of vaginal clamp.
Cystoscope assembly, part 1. Video courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.
Cystoscope assembly, part 2. Video courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.
Cystoscopy, part 1. Video courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.
Cystoscopy, part 2. Video courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.
Cystoscopy supplies. Image courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.
Cystolithotripsy, part 1. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
Cystolithotripsy, part 2. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
Cystolithotripsy, part 3. Video courtesy of Dennis G Lusaya, MD, and Edgar V Lerma, MD.
Gross anatomy of the bladder.
 
 
 
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