Editing Cystoscopy

{{Short description|Medical procedure; endoscopy of the urinary bladder via the urethra}}
{{cs1 config|name-list-style=vanc}}
{{Infobox medical intervention
|  Name        = Cystoscopy
|  Image       = Diagram showing a cystoscopy for a man and a woman CRUK 064.svg
|  Caption     = Diagram showing a cystoscopy for a male and a female
| pronounce    = sis-ˈtäs-kə-pē
|  ICD10       =
|  ICD9        = {{ICD9proc|57.31}}-{{ICD9proc|57.33}}
|  MeshID      = D003558
|  MedlinePlus = 003903
|  OtherCodes  =
}}

'''Cystoscopy''' is [[endoscopy]] of the [[urinary bladder]] via the [[urethra]]. It is carried out with a '''cystoscope'''.

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 physician focus on the inner surfaces of the [[urinary tract]]. Some cystoscopes use [[optical fiber|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 pediatric to adult and from the thickness of a pencil up to approximately 9&nbsp;mm 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 [[stiffness|rigid]]—differing in the flexibility of the cystoscope. Flexible cystoscopy is carried out with local anaesthesia on both sexes. Typically, a topical anesthetic, most often [[lidocaine|xylocaine]] gel (common brand names are Anestacon and Instillagel) is employed. The medication is instilled into the urethra via the [[urinary meatus]] five to ten minutes prior to the beginning of the procedure. Rigid cystoscopy can be performed under the same conditions, but is generally carried out under general anesthesia, particularly in male subjects, due to the pain caused by the probe. The sizes of the sheath of the rigid cystoscope are 17 [[French catheter scale|French gauge]] (5.7&nbsp;mm diameter), 19 Fr gauge (6.3&nbsp;mm diameter), and 22 Fr gauge (7.3&nbsp;mm diameter).

== Medical uses ==

[[File:Cystoscope-med-20050425.jpg|thumb|A sterile flexible cystoscope in an [[operating theatre]]]]
Cystoscopy may be recommended for any of the following conditions:<ref>{{cite web | url = http://www.doctorslounge.com/urology/procedures/cystoscopy.htm | title = Cystoscopy and Ureteroscopy | work = The Doctors Lounge | access-date = 2008-01-29 | archive-date = 2011-07-10 | archive-url = https://web.archive.org/web/20110710143130/http://www.doctorslounge.com/urology/procedures/cystoscopy.htm | url-status = dead }}</ref>
* [[urinary tract infection]]s;
* [[blood]] in the urine ([[hematuria]]);
* loss of bladder control ([[Urinary incontinence|incontinence]]) or [[overactive bladder]]; (Although, the American Urogynecologic Society does not recommend that cystoscopy, urodynamics, or diagnostic renal and bladder ultrasound are part of initial diagnosis for uncomplicated overactive bladder.)<ref name="AUSFive">{{cite web |author1 = American Urogynecologic Society|author1-link = American Urogynecologic Society |date = May 5, 2015 |title = Five Things Physicians and Patients Should Question |publisher = American Urogynecologic Society |work = [[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |url = http://www.choosingwisely.org/societies/american-urogynecologic-society/ |access-date = June 1, 2015}}</ref><ref>{{cite journal | vauthors = Gormley EA, Lightner DJ, Faraday M, Vasavada SP | title = Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline amendment | journal = The Journal of Urology | volume = 193 | issue = 5 | pages = 1572–80 | date = May 2015 | pmid = 25623739 | doi = 10.1016/j.juro.2015.01.087 }}</ref>
* unusual cells found in urine sample;
* need for a bladder [[catheter]];
* painful urination, chronic [[pelvic pain]], or [[interstitial cystitis]];
* urinary blockage such as from [[prostate]] enlargement, [[Urethral stricture|stricture]], or narrowing of the urinary tract;
* [[Kidney stone|stone]] in the urinary tract; and
* unusual growth, [[Polyp (medicine)|polyp]], [[tumor]], or [[cancer]].

== Male and female urinary tracts ==

[[Image:Cystoscopy-im-20050425.jpg|thumb|Images from a cystoscopy. The top two images show the interior of the [[urinary bladder|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 [[Inflammation|inflamed]] [[urethra]].]]
If a patient has a stone lodged higher in the urinary tract, the physician 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 physician can then see the stone and remove it with a small basket at the end of a wire that is inserted through an extra tube in the ureteroscope.  For larger stones, the physician 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.{{cn|date=February 2022}}

== Test procedures ==

Physicians 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 of 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 physicians 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 his or her knees raised. This is particularly true 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 physician, nurse, or technician will clean the area around the [[urinary meatus|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 [[chlorhexidine]].<ref>{{cite web |url=http://www.rxmed.com/b.main/b2.pharmaceutical/b2.1.monographs/CPS-%20Monographs/CPS-%20(General%20Monographs-%20H)/HIBITANE.html |title=Pharmaceutical Information – Hibitane |publisher=RxMed |access-date=2013-06-09 |url-status=dead |archive-url=https://web.archive.org/web/20140203163920/http://www.rxmed.com/b.main/b2.pharmaceutical/b2.1.monographs/CPS-%20Monographs/CPS-%20%28General%20Monographs-%20H%29/HIBITANE.html |archive-date=2014-02-03 }}</ref>

Patients receiving a ureteroscopy may receive a [[spinal anaesthesia|spinal]] or [[general anaesthetic]].

The physician 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]], and results of a 2019 systematic review of the literature found that intraurethral lidocaine greatly reduces this painful procedure in men.<ref>{{Cite journal |last1=Raskolnikov |first1=Dima |last2=Brown |first2=Benjamin |last3=Holt |first3=Sarah K. |last4=Ball |first4=Andrea L. |last5=Lotan |first5=Yair |last6=Strope |first6=Seth |last7=Schroeck |first7=Florian |last8=Ullman |first8=Ralph |last9=Lipman |first9=Robert |last10=Smith |first10=Angela B. |last11=Gore |first11=John L. |date=2019 |title=Reduction of Pain during Flexible Cystoscopy: A Systematic Review and Meta-Analysis |url=http://www.auajournals.org/doi/10.1097/JU.0000000000000399 |journal=Journal of Urology |language=en |volume=202 |issue=6 |pages=1136–1142 |doi=10.1097/JU.0000000000000399 |pmid=31219763 |s2cid=195192577 |issn=0022-5347}}</ref> Relaxing the [[pelvic muscles]] helps make this part of the test easier.  A [[Sterilization (microbiology)|sterile]] liquid (water, [[saline (medicine)|saline]], or [[glycine]] solution) will flow through the cystoscope to slowly fill the bladder and stretch it so that the physician has a better view of the bladder wall.

As the bladder reaches capacity, patients typically feel some mild discomfort and the urge to urinate.{{cn|date=February 2022}}

The time from insertion of the cystoscope to removal may be only a few minutes, or it may be longer if the physician 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.{{cn|date=February 2022}}

=== Blue light ===

In blue light cystoscopy [[hexyl aminolevulinate hydrochloride]] is instilling a photosensitizing agent, into the bladder. The blue light cystoscopy contains a light source and light is transmitted through a fluid light cable connected to an endoscope to light up the area to be observed. The photosensitizing agent preferentially accumulates [[porphyrin]]s in malignant cells as opposed to nonmalignant cells of urothelial origin. Under subsequent blue light illumination, [[neoplasm|neoplastic lesions]] fluoresce red, enabling visualization of tumors. The blue light cystoscopy is used to detect non-muscle invasive papillary cancer of the bladder.<ref>{{cite web | url = https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm215427.htm | archive-url = https://web.archive.org/web/20170118090751/https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm215427.htm | archive-date = 18 January 2017 | publisher = FDA | title = Photodynamic Diagnostic D-Light C (PDD) System – P050027 }}</ref><ref name="pmid22512972">{{cite journal | vauthors = Mark JR, Gelpi-Hammerschmidt F, Trabulsi EJ, Gomella LG | title = Blue light cystoscopy for detection and treatment of non-muscle invasive bladder cancer | journal = The Canadian Journal of Urology | volume = 19 | issue = 2 | pages = 6227–31 | date = April 2012 | pmid = 22512972 | doi = | url = http://www.canjurol.com/pdfs/HOW/HOW-DrMark.pdf }}</ref>

== Indications before and after the procedure ==

=== Before the procedure ===
Prior to the early 1990s, it was common practice for the physician performing the procedure to prescribe an [[antibiotic]] to take for a few days to prevent an [[infection]]. Since that time, many urologists will order a "urine C & S" ([[urinalysis]] with bacterial/fungal cultures and testing for sensitivities to anti-infective medications) prior to the performance of the cystoscopy, and as part of the pre-operative workup. Depending on the results of the testing and other circumstances, he or she may elect to prescribe a 10- to 14-day course of antibiotic or other anti-infective treatment, commencing 3 days before the cystoscopy is to be performed, as this may alleviate some inflammation of the urethra prior to the procedure.{{cn|date=February 2022}}

This practice may provide an additional benefit by preventing an accidental infection from occurring during the procedure. When antibiotics are given for UTI prevention in adults undergoing a cystoscopy, they may reduce the risk of infections that go into the bloodstream and infections limited to the bladder.<ref name="Zeng_2019">{{cite journal | vauthors = Zeng S, Zhang Z, Bai Y, Sun Y, Xu C | title = Antimicrobial agents for preventing urinary tract infections in adults undergoing cystoscopy | journal = The Cochrane Database of Systematic Reviews | volume = 2019 | pages = CD012305 | date = February 2019 | issue = 2 | pmid = 30789676 | pmc = 6383548 | doi = 10.1002/14651858.CD012305.pub2 | collaboration = Cochrane Urology Group }}</ref> However, antibiotics may have little to no effect on only the risk of serious infections that go in the bloodstream. From review data, antibiotics do not appear to cause serious unwanted side effects or affect the occurrence of minor side effects, but more research is needed to confirm these findings.<ref name="Zeng_2019" /> The full-course of antibiotic treatment also lessens the possibility of the bacteria becoming resistant to the antibiotic/anti-infective agent prescribed.

Physicians may also prescribe an oral urinary [[analgesic]], [[phenazopyridine]], or a combination (urinary) analgesic/anti-infective/[[anti-spasmodic]] medication containing [[Methylene Blue|methylene blue]], [[methanamine]], [[hyoscyamine sulfate]] and [[phenyl salicylate]] for irritation and/or [[dysuria]] patients may experience after the procedure. At two weeks post-procedure, the practitioner may order a follow-up evaluation including a repeat of the urinalysis with cultures and sensitivities, and a uroflowmetric study (which evaluates the volume of urine released from the body, the speed with which it is released, and how long the release takes)

=== After the procedure ===
Patients often experience a burning sensation during urination and often see small amounts of blood in their urine. Procedures using rigid instrumentation more frequently result in short-term [[urinary incontinence]] and leakage due to urethral damage. Occasionally, patients may feel some [[lower abdominal pain]]s, reflecting bladder [[muscle spasms]], but these are not common.

Common (non-invasive) prescriptions to relieve discomfort after the test may include:
* drinking 32 fluid ounces (1 L) of water over 2 hours;
* taking a warm bath to relieve the burning feeling; and
* holding a warm, damp washcloth over the urethral opening.

== Other animals ==

Cystoscopy has similar indications in animals, including visualisation and biopsy of mucosa, retrieval or destruction of urinary bladder stones and diagnosis of ectopic ureters.<ref name="pmid26002795">{{cite journal | vauthors = Morgan M, Forman M | title = Cystoscopy in dogs and cats | journal = The Veterinary Clinics of North America. Small Animal Practice | volume = 45 | issue = 4 | pages = 665–701 | date = July 2015 | pmid = 26002795 | doi = 10.1016/j.cvsm.2015.02.010 | department = review }}</ref><ref name="pmid21801049">{{cite journal | vauthors = Childress MO, Adams LG, Ramos-Vara JA, Freeman LJ, He S, Constable PD, Knapp DW | title = Results of biopsy via transurethral cystoscopy and cystotomy for diagnosis of transitional cell carcinoma of the urinary bladder and urethra in dogs: 92 cases (2003-2008) | journal = Journal of the American Veterinary Medical Association | volume = 239 | issue = 3 | pages = 350–6 | date = August 2011 | pmid = 21801049 | doi = 10.2460/javma.239.3.350 }}</ref><ref name="pmid20632793">{{cite journal | vauthors = Smith AL, Radlinsky MG, Rawlings CA | title = Cystoscopic diagnosis and treatment of ectopic ureters in female dogs: 16 cases (2005-2008) | journal = Journal of the American Veterinary Medical Association | volume = 237 | issue = 2 | pages = 191–5 | date = July 2010 | pmid = 20632793 | doi = 10.2460/javma.237.2.191 | doi-access = free }}</ref>

In [[turtle]] and tortoises, cystoscopy has additional value as it permits the visualisation of internal organs due to the thin [[urinary bladder]] wall.<ref name="pmid26336001">{{cite journal | vauthors = Di Girolamo N, Selleri P | title = Clinical Applications of Cystoscopy in Chelonians | journal = The Veterinary Clinics of North America. Exotic Animal Practice | volume = 18 | issue = 3 | pages = 507–26 | date = September 2015 | pmid = 26336001 | doi = 10.1016/j.cvex.2015.04.008 }}</ref> In young individuals in which [[sexing|sex determination]] would not be feasible by visualisation of external morphologic features, this technique permits noninvasive visualisation of gonads, and therefore sex determination.<ref name="pmid23725439">{{cite journal | vauthors = Selleri P, Di Girolamo N, Melidone R | title = Cystoscopic sex identification of posthatchling chelonians | journal = Journal of the American Veterinary Medical Association | volume = 242 | issue = 12 | pages = 1744–50 | date = June 2013 | pmid = 23725439 | doi = 10.2460/javma.242.12.1744 }}</ref>

== References ==

{{Reflist}}
* ''An earlier version of this article was adapted from the [[public domain]] [https://web.archive.org/web/20021002164707/http://www.niddk.nih.gov/health/kidney/pubs/cystoscopy/cystoscopy.htm NIH Publication No. 01-4800], which says, "This e-text is not copyrighted. The clearinghouse encourages users of this e-pub to duplicate and distribute as many copies as desired."''

== Further reading ==
* [https://web.archive.org/web/20150329184704/http://kidney.niddk.nih.gov/kudiseases/pubs/cystoscopy/ Cystoscopy and Ureteroscopy on the ''National Institute of Diabetes and Digestive and Kidney Diseases'' website]

{{Urologic surgical and other procedures}}
{{Endoscopy}}
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[[Category:Endoscopy]]
[[Category:Urologic procedures]]