Chapter 13: Diagnostic tests
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Cystoscopy
Definition
A flexible cystoscopy is a camera examination used to visualize the lower urinary tract, including the urethra (or prostatic urethra), sphincter, bladder and ureteric orifices. Cystoscopy can assist in identifying problems with the urinary tract, such as early signs of bladder cancer, infection, strictures, obstruction, bleeding and other abnormalities; it is also used for surveillance of bladder cancer. Furthermore, it is an effective method for removing ureteric stents when they are no longer therapeutically indicated and in some cases treating bladder abnormalities. The procedure is performed under local anaesthetic with the patient awake in a dedicated outpatient facility (Kumar and Clark [120], Tortora and Derrickson [243]).
Anatomy and physiology
Urethra
The urethra extends from the external urethral orifice to the bladder (Tortora and Derrickson [243]).
Male urethra
The male urethra is approximately 20 cm long and provides a common pathway for urine, semen and reproductive organ secretions. The three parts of the male urethra are the prostatic urethra, the membranous urethra and the spongy or penile urethra. Originating at the urethral orifice of the bladder, the prostatic urethra passes through the prostate gland (Figure 13.30). The narrowest and shortest part of the urethra is the membranous urethra, originating at the prostate gland and extending to the bulb of the penis. The penile urethra ends at the urethral orifice (Tortora and Derrickson [243]).
Figure 13.30 Cystoscopy for a man. Source: Reproduced with permission of the patient information website of Cancer Research UK (www.cancerresearchuk.org/cancerhelp).
Female urethra
The female urethra is located behind the symphysis pubis and opens at the external urethral orifice (Figure 13.31). It is approximately 4 cm long (Tortora and Derrickson [243]).
Figure 13.31 Cystoscopy for a woman. Source: Reproduced with permission of the patient information website of Cancer Research UK (www.cancerresearchuk.org/cancerhelp).
Evidence‐based approaches
Rationale
A cystoscopy is undertaken to gain direct visualization of the urethra and the bladder to aid diagnosis of urological complications and diseases such as bladder cancer (British Association of Urological Surgeons [23], Pagana and Pagana [177]).
Indications
Indications for cystoscopy include:
- bladder dysfunction
- unexplained haematuria
- diagnosis of bladder cancer
- staging of bladder cancer
- obstruction or strictures
- dysuria.
Contraindications
Confirmed urinary tract infection (UTI) is a contraindication for cystoscopy.
Pre‐procedural considerations
Equipment
A cystoscope may be flexible or rigid. A rigid cystoscope is utilized in the operating theatre, where the patient is anaesthetized. The flexible cystoscope (Figure 13.32) is used with a video stack (Figure 13.33) and can be used in the outpatient setting with local anaesthesia. The flexible cystoscope is useful for patients who require more regular examinations for follow‐up after bladder cancer treatment (Chernecky and Berger [32], Fillingham and Douglas [61], Pagana and Pagana [177]).
Figure 13.32 A flexible cystoscope. Source: Reproduced from Dougherty et al. ([54]). © 2019 The Royal Marsden NHS Foundation Trust. Published 2019 by John Wiley & Sons, Ltd.
Figure 13.33 A video stack.
Specific patient preparation
It is essential that the patient does not have a UTI as the organism responsible for the infection may be spread into the bloodstream during the procedure. A dipstick and/or midstream urine test should be performed at least one week prior to a flexible cystoscopy to exclude a UTI. If the patient is having a general anaesthetic, they will have to fast prior to the procedure, depending on anaesthetic instruction. Prior to the procedure, patients undergoing a local anaesthetic can usually eat and drink as normal and should empty their bladder prior to the procedure. It may be necessary for some patients to be treated with antibiotics before the procedure to reduce the risk of infection (American Urological Association [6], Pagana and Pagana [177]).
Post‐procedural considerations
Immediate care
Depending on the type of procedure, recovery will vary. After a general anaesthetic, the patient will recover under the care of dedicated nursing staff. In the outpatient setting, physiological observations may be required. Nursing staff should monitor the patient for signs of haematuria, infection, urinary retention and excessive pain in the abdomen or urethral area. It is also possible that the patient may experience bladder spasms, which can be minimized with prescribed analgesics. Oral fluids should be encouraged (Chernecky and Berger [32], Pagana and Pagana [177]).
Ongoing care
It is common for patients to experience some burning sensations while passing urine for a few days. It is advised that patients drink plenty of water post‐procedure to flush the bladder and reduce the risk of infection. Any signs of excessive bleeding should be reported to the medical team (Chernecky and Berger [32], Pagana and Pagana [177]).
