Cystoscopy 

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

Overview

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.

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.

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]

 

Periprocedural Care

Equipment

The materials required for cystoscopy (see the image below) include a cystoscope, a video system, and an irrigating medium.

Cystoscopy supplies. Image courtesy of Michel Rivl Cystoscopy supplies. Image courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.

Cystoscope

A rigid cystoscope (see the image below) is composed of 3 parts: telescope, bridge, and sheath. The telescope transmits the light into the urinary bladder and the image to the examiner. The telescopes have different viewing angles (eg, 0°, 12°, 25°, 30°, 70°, or 120°), each with its own viewing capabilities and indications. The 0° and 12° devices angle downward. This helps to visualize the whole bladder.

Rigid cystoscope with connections to irrigation an Rigid cystoscope with connections to irrigation and light source.

Of particular importance is retrograde visualization of the bladder neck area, which could not be achieved with the rigid cystoscope. The flexible cystoscope (see the image below) is less painful to the patient,[7] permits inspection of the entire bladder with a single optical instrument, and is invaluable when the patient cannot be placed in the lithotomy position, as in cases of frozen pelvis, limb deformities, or joint diseases.

Flexible cystoscope. Flexible cystoscope.

The major disadvantage of the flexible cystoscope is the limited irrigation flow port, which impairs the visualization process. The use of working instruments through the same port results in further impairment of visualization, as well as limits the deflection mechanism.

Assembly of a cystoscope is depicted in the videos below.

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.

Video system

The advance of videoendoscopy has improved cystoscopy considerably, providing a more comfortable position for the examiner, reducing the chances of soiling and contamination for the operating team, enhancing teaching techniques, and enabling video recording. Videoendoscopy allows patients to watch the important cystoscopic findings and become more aware of their conditions.

Irrigating medium

The most commonly used irrigating media are sterile water and normal saline. Normal saline should not be used when electrocauterization is attempted; sterile water should not be used when bladder samples are collected for cytologic evaluation.

The irrigating medium should be warmed to body temperature before use. It flows under the effect of gravity; no additional external pressure is needed.

Patient Preparation

The introduction of flexible endoscopes has led to a reduction in the use of sedation, topical anesthetics, and general anesthesia for cystourethroscopy. In the author’s practice, flexible cystoscopy as a diagnostic procedure is performed without the use of analgesia or sedation. A non-randomized study by Cano-Garcia et al found that there is no pain relief benefit in the use of lidocaine gel vs. lubricant gel in flexible cystoscopy.[8] This supports the findings of a meta-analysis of 9 prospective randomized controlled trials by Patel et al.[9]

Those who prefer a rigid cystoscope or are performing an office procedural cystoscopy that necessitates the use of a rigid cystoscope typically instill local lidocaine gel into the urethra 10-15 minutes before the procedure, with or without mild sedation.[10] Some studies support the use of lidocaine spray, which takes effect more quickly (within 1-5 minutes).[1] This option may reduce anxiety in patients waiting for the procedure, as well as save time in the setting of a busy clinic.

The most commonly used position for cystoscopy is the lithotomy position. However, most males undergoing flexible cystoscopy in the clinic can be examined in the supine position.

 

Technique

Endoscopy of Urinary Bladder

The patient is positioned on the cystoscopy table, prepared, and draped in the usual sterile manner. Before the scope is inserted, 2% lidocaine gel is inserted into the urethra and left for 5 minutes. The patient is warned about some increased discomfort at the level of the external urethral sphincter. When a rigid cystoscope is used in a female patient, it should be introduced with its obturator to minimize urethral trauma and pain.

The flexible cystoscope is then inserted under direct vision and navigated to the bladder. It is critical to remain aware of the major landmarks at all times. Urethral orifices and air bubbles are the most important landmarks.

The bladder is examined in a systematic manner (see the videos and images below). The trigone, the bladder neck, and both ureteral orifices are identified. The bladder base and the posterior bladder wall are examined, and the air bubble is identified. The lateral walls are examined, and the test is concluded by visualizing the urethra.

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.
Bladder distention in patient with interstitial cy Bladder distention in patient with interstitial cystitis.
Large supratrigonal vesicovaginal fistula, showing Large supratrigonal vesicovaginal fistula, showing tip of vaginal clamp.

Cystoscopy may also be performed for therapeutic purposes, as in cystolithotripsy (see the videos below).

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.

Complications

In general, the complications of cystoscopy are usually minor and may include the following:

  • Urinary tract infection[11]

  • Hematuria

  • Dysuria

  • Bladder or urethral injury

Approach Considerations

A study by Seklehner et al found that flexible diagnostic cystoscopy caused less pain than rigid cystoscopy in men.[12]

 

Medication

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Local Anesthetics, Amides

Class Summary

Local anesthetics block the initiation and conduction of nerve impulses. Anesthetics used for the cystoscopy include lidocaine.

Lidocaine (Xylocaine)

Lidocaine inhibits depolarization of type C sensory neurons by blocking sodium channels. Instill local lidocaine gel into the urethra 10-15 minutes before the procedure.

Those who prefer a rigid cystoscope or are performing an office procedural cystoscopy that necessitates the use of a rigid cystoscope typically instill local lidocaine gel into the urethra 10-15 minutes before the procedure. Some studies support the use of lidocaine spray, which takes effect more quickly (within 1-5 min).[1] This option may reduce anxiety in patients waiting for the procedure, as well as save time in the setting of a busy clinic.

Antibiotics

Class Summary

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 administered. Patients with negative urine cultures and those without any of these risk factors do not need antibiotic prophylaxis before cystourethroscopy.

Trimethoprim/sulfamethoxazole (Bactrim DS, Septra DS)

Trimethoprim blocks dihydrofolate reductase, and sulfamethoxazole inhibits bacterial synthesis of dihydrofolic acid by competing with para-aminobenzoic acid (PABA). These are 2 sequential steps in bacterial biosynthesis of nucleic acids and proteins. This agent is available in single- and double-strength form. In adults, it is most commonly taken in pill form, although a liquid suspension is available.

Levofloxacin (Levaquin)

A derivative of pyridine carboxylic acid with a broad-spectrum bactericidal effect, levofloxacin penetrates the prostate well and is effective against Neisseria gonorrhoeae and Chlamydia trachomatis.

Ciprofloxacin (Cipro)

Ciprofloxacin is a fluoroquinolone with activity against pseudomonads, streptococci, methicillin-resistant Staphylococcus aureus (MRSA), Staphylococcus epidermidis, and most gram-negative organisms, but no activity against anaerobes. It inhibits bacterial DNA synthesis and, consequently, growth. It diffuses into prostatic fluid and is indicated for chronic prostatitis.

Ampicillin

Ampicillin has bactericidal activity against susceptible organisms. It is an alternative to amoxicillin when the patient is unable to take medication orally.

Amoxicillin (Moxatag)

Amoxicillin is an ampicillin analogue with broad-spectrum bactericidal activity against many gram-positive and gram-negative organisms.

Cefuroxime axetil (Ceftin, Zinacef)

Cefuroxime is a second-generation cephalosporin that maintains the gram-positive activity of the first-generation cephalosporins and adds activity against Proteus mirabilis, Haemophilus influenzae, Escherichia coli, Klebsiella pneumoniae, and Moraxella catarrhalis. The condition of patient, the severity of the infection, and the susceptibility of the microorganism determine the proper dose and route of administration.

Cefprozil

Cefprozil binds to 1 or more of the penicillin-binding proteins, and this binding, in turn, inhibits cell wall synthesis and results in bactericidal activity.

Cephalexin (Keflex)

Cephalexin is a first-generation cephalosporin that arrests bacterial growth by inhibiting bacterial cell wall synthesis. It has bactericidal activity against rapidly growing organisms. The primary activity of cephalexin is against skin flora; the drug is used for skin infections or prophylaxis in minor procedures.

Gentamicin

Gentamicin is an aminoglycoside antibiotic for gram-negative coverage of bacteria, including Pseudomonas species. It is synergistic with beta-lactamase against enterococci. Gentamicin interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits. Dosing regimens are numerous and are adjusted based on creatinine clearance and changes in volume of distribution, as well as the body space into which the agent needs to distribute. Monitor gentamicin by serum levels obtained before the third or fourth dose (0.5 h before dosing); the peak level may be drawn 0.5 hour after a 30-minute infusion.