Cystoscopy and Urethroscopy in the Assessment of Urinary Incontinence 

  • Author: Raymond Rackley, MD; Chief Editor: Edward David Kim, MD, FACS   more...
 
Updated: Jun 7, 2011
 

Overview

Cystourethroscopy allows an anatomical assessment of the bladder and the urethra. The precise role of cystourethroscopy in the evaluation of female urinary incontinence is controversial. Fewer than 2% of bladder tumors have been identified by routinely performing cystoscopy in incontinent women.

On the other hand, cystoscopy helps detect bladder lesions, such as a foreign body (eg, suture, mesh material from prior surgery for prolapse or incontinence), bladder cancer, and bladder stones, which would otherwise remain undiagnosed if only urodynamic findings are assessed. A visual inspection of the urethra helps establish the presence of urethral stricture or gross evidence of poor urethral closure.

The general agreement is that cystoscopy is indicated for patients with persistent irritative voiding symptoms or hematuria, persistent postoperative incontinence, voiding dysfunction, and findings suggestive of a diverticulum or fistula. Obvious causes of bladder overactivity, such as cystitis, stone, and tumor, can be easily diagnosed. This information is important in determining the etiology of the incontinence and may influence treatment decisions.

For other discussions on urinary incontinence, see Urinary Incontinence, as well as Urodynamic Studies for Urinary Incontinence and Urinary Incontinence Relevant Anatomy.

The authors routinely use a flexible cystoscope (see the images below) rather than a rigid cystoscope. A flexible cystoscope has excellent optics and enhances patient comfort during the examination. The authors also perform urethroscopy to assess the structure and function of the urethral sphincter mechanism.

A flexible cystoscope is used to evaluate the anatA flexible cystoscope is used to evaluate the anatomy of the bladder and the urethra. A flexible cystoscope is less rigid and more comfortable for the patient than the rigid cystoscope. Urinary incontinence. Free-flowing indigo carmine Urinary incontinence. Free-flowing indigo carmine is observed from the ureteral orifice during intraoperative cystoscopy.

Comparisons of cystourethroscopy and multichannel urodynamics show the latter to be more sensitive and specific in diagnosing stress incontinence and detrusor overactivity. Nevertheless, cystourethroscopy may contribute to an anatomic and functional assessment of the lower urinary tract; thus, in combination with urodynamics, this procedure aids in making the correct diagnosis. (See Urodynamic Studies for Urinary Incontinence for more information on this topic.)

A fixed, rigid, nonfunctioning urethra can be a finding in severe cases of intrinsic sphincter deficiency. Rounding of the urethra or the presence of bladder trabeculations (thick, bandlike cords of detrusor muscle) during bladder filling may point to the diagnosis of detrusor overactivity (see the images below).

Rounding of the urethra at the level of the bladdeRounding of the urethra at the level of the bladder neck suggests detrusor instability (DI). Pale white detrusor bands are observed against a vPale white detrusor bands are observed against a vascular mucosal background during an episode of detrusor instability (DI).

Bladder neck fronds and polyps or cystitis cystica can indicate past or chronic inflammation. Occasionally, such unexpected findings as foreign bodies, stones, and neoplasms may be revealed. Finally, urinary tract fistulas, diverticular openings, and functional ureteral abnormalities can be visualized with cystourethroscopy.

A retrospective study of 84 patients in a referral urogynecology practice illustrated the potential importance of cystourethroscopy in incontinence evaluations: in 19% of the cases, a cystourethroscopic finding changed patient management. These findings included an intravesical suture, a urethral diverticulum, 2 cases of bladder cancer, and 2 cases of cystitis glandularis. In addition, a group of patients had urethroscopic findings that contributed to the ultimate diagnosis of intrinsic sphincter deficiency.[1]

In most other cases, cystourethroscopic findings supported the urodynamic diagnosis. These researchers concluded that cystourethroscopy goes hand-in-hand with urodynamic testing and may enhance the diagnostic accuracy of the latter. Of note, patients with malignant and premalignant conditions of the bladder did not have the classic symptoms of pain and hematuria and did not necessarily have other commonly associated characteristics and risk factors such as age over 60 years, urinary urgency, and detrusor overactivity.

Other methods, such as fluoroscopy and videourodynamics, can be used to perform anatomic assessments of the lower urinary tract. These methods are more costly and less readily available in clinical practice. More research is needed to further define the role of cystourethroscopy in urinary incontinence evaluations.

Next

Dynamic Retrograde Urethroscopy

In this technique, the cystoscope is introduced into the bladder. The bladder is filled to 250 mL with irrigant. The flow of the irrigant is turned off. The cystoscope is withdrawn to the mid-urethra. The activity of the urethral sphincter mechanism is observed at rest and with Valsalva maneuvers.

Patients with stress urinary incontinence due to urethral hypermobility whose urethra is normal have a closed bladder neck at rest, with an intact voluntary guarding reflex (see the images below). Patients with stress incontinence due to intrinsic sphincter deficiency have an open bladder neck at rest but have an impaired voluntary guarding reflex (see the images below).

This shows normal findings from a dynamic retrograThis shows normal findings from a dynamic retrograde urethroscopy; the urinary sphincter is closed at rest (Figure a), is closed with stress maneuvers (Figure b), and has excellent guarding reflex (Figure c). Note the urinary sphincter is contracted and elevated in Figure c; this is a normal guarding reflex. This shows classic type-II stress urinary incontinThis shows classic type-II stress urinary incontinence seen on dynamic retrograde urethroscopy. Note that the sphincter is closed at rest (Figure a), remains open with stress maneuvers (Figure b), and has good guarding reflex (Figure c). Patients with classic type-II stress urinary incontinence are able to close their urinary sphincters voluntarily. This shows classic type-III stress urinary incontiThis shows classic type-III stress urinary incontinence seen on dynamic retrograde urethroscopy. Note that the sphincter is open at rest (Figure a), remains open with stress maneuvers (Figure b), and has weak guarding reflex (Figure c). Patients with classic intrinsic sphincter deficiency a have a difficult time closing their urinary sphincters voluntarily.
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Contributor Information and Disclosures
Author

Raymond Rackley, MD  Professor of Surgery, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University; Staff Physician, Center for Pelvic Medicine and Pelvic Reconstruction, Glickman Urological Institute, Cleveland Clinic Foundation

Raymond Rackley, MD is a member of the following medical societies: American Urological Association

Disclosure: Pfizer, Novartis, Proctor & Gamble, Allergan Honoraria None; Pfizer, Novartis, Proctor & Gamble, Allergan Consulting fee Other

Specialty Editor Board

Martha K Terris, MD, FACS  Professor, Department of Surgery, Section of Urology, Director, Urology Residency Training Program, Medical College of Georgia; Professor, Department of Physician Assistants, Medical College of Georgia School of Allied Health; Chief, Section of Urology, Augusta Veterans Affairs Medical Center

Martha K Terris, MD, FACS is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Institute of Ultrasound in Medicine, American Society of Clinical Oncology, American Urological Association, Association of Women Surgeons, New York Academy of Sciences, Society of Government Service Urologists, Society of University Urologists, Society of Urology Chairpersons and Program Directors, and Society of Women in Urology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark Jeffrey Noble, MD  Consulting Staff, Urologic Institute, Cleveland Clinic Foundation

Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, and Southwest Oncology Group

Disclosure: Nothing to disclose.

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, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association

Disclosure: Lilly Consulting fee Advisor; Astellas Consulting fee Speaking and teaching; Watson Consulting fee Speaking and teaching; Allergan Consulting fee Speaking and teaching

References

  1. Weinberger MW. Cystourethroscopy for the practicing gynecologist. Clin Obstet Gynecol. Sep 1998;41(3):764-76. [Medline].

 
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A flexible cystoscope is used to evaluate the anatomy of the bladder and the urethra. A flexible cystoscope is less rigid and more comfortable for the patient than the rigid cystoscope.
Urinary incontinence. Free-flowing indigo carmine is observed from the ureteral orifice during intraoperative cystoscopy.
Rounding of the urethra at the level of the bladder neck suggests detrusor instability (DI).
Pale white detrusor bands are observed against a vascular mucosal background during an episode of detrusor instability (DI).
This shows normal findings from a dynamic retrograde urethroscopy; the urinary sphincter is closed at rest (Figure a), is closed with stress maneuvers (Figure b), and has excellent guarding reflex (Figure c). Note the urinary sphincter is contracted and elevated in Figure c; this is a normal guarding reflex.
This shows classic type-II stress urinary incontinence seen on dynamic retrograde urethroscopy. Note that the sphincter is closed at rest (Figure a), remains open with stress maneuvers (Figure b), and has good guarding reflex (Figure c). Patients with classic type-II stress urinary incontinence are able to close their urinary sphincters voluntarily.
This shows classic type-III stress urinary incontinence seen on dynamic retrograde urethroscopy. Note that the sphincter is open at rest (Figure a), remains open with stress maneuvers (Figure b), and has weak guarding reflex (Figure c). Patients with classic intrinsic sphincter deficiency a have a difficult time closing their urinary sphincters voluntarily.
 
 
 
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