Marc Laniado MD FRCS(Urol) FEBU
CONSULTANT IN UROLOGY

Table of Contents

1. What is a cystoscopy
2. What is a flexible cystoscope?
3. Why is a flexible cystoscopy done?
4. What preparation is required before a flexible cystoscopy?
5. What happens during a flexible cystoscopy?
6. What to expect afterwards?
7. Are there any side-effects or complications?
8. Are there alternatives to flexible cystoscopy?

What is a cystoscopy?

Cystoscopy: the name for a procedure allowing a doctor to look into the bladder with a special telescope called a cystoscope.

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What is a flexible cystoscopy?

A flexible cystoscope is a thin telescope which is passed into the bladder via the urethra (the tube that takes urine from your bladder to the outside of your body). Sometimes, it is called a ‘diagnostic flexible cystoscopy’, ‘check flexible cystoscopy’, or ‘review flexible cystoscopy’. The flexible cystoscope is a thin, flexible, fiber-optic telescope. It is about as thick as a pencil. The fibre-optics allow a doctor to see around bends.

A doctor can look down the flexible cystoscope, and also pictures can be displayed on a TV monitor. It should be possible for you to see the same pictures and images that are seen by the doctor on the TV monitor. There are side channels in the flexible cystoscope and it is possible to pass various thin devices through these channels if an additional procedure is planned.

A flexible cystoscope is the most commonly performed type of cystoscopy. As it is flexible, it usually passes easily along the curves of the urethra. The flexible tip can also be moved easily so a doctor can look at all the inside lining of the bladder. However, a rigid cystoscope allows a greater variety of devices to pass down side channels which may be needed for various procedures. Sometimes, it is necessary to perform a rigid cystoscopy at a later date after a flexible cystoscopy.

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Why is a flexible cystoscopy done?

To help with diagnosis

A cystoscopy may be done to help to find the cause of symptoms such as:

• Difficulty in passing urine (which may be due to prostate enlargement or a stricture (narrowing) of the urethra).

• Frequent urinary tract infections.

• Blood in the urine (haematuria).

• Incontinence.

• Unusual cells found in a urine sample.

• Persistent pain when you pass urine.

Cystoscopy may also be done to monitor progress of conditions. For example, some people have a routine cystoscopy every now and then after treatment for a bladder tumour. This helps to detect any early recurrence which can be treated before it spreads further. Often a cystoscopy is normal, but is necessary to rule-out certain causes of your symptoms. To remove a JJ stent placed after procedures performed on the kidney or ureter.

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What preparation is required before a flexible cystoscopy?

A flexible cystoscopy is usually done as an outpatient whilst you are awake. Although the test may take less than 5 minutes to perform, you should allow at least one to two hours in hospital for this procedure. Do not plan important events afterwards as you may have bothersome urinary symptoms after. It is better if someone can take you home afterwards.

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What happens during a flexible cystoscopy?

A nurse will take you to a room where you will change into a hospital gown. You will be asked to empty your bladder. Then you will be taken into another room and asked to lie on your back on a couch. The opening to your urethra (at the end of the penis or the outside of the vagina) and the nearby skin will be cleaned. Some 'jelly' is then squirted into the opening of the urethra. The jelly usually contains a local anaesthetic to numb the lining of the urethra. This helps the cystoscope to pass into the urethra with as little discomfort as possible. It also reduces the quantity of bacteria present.

The doctor will gently pass the flexible cystoscope through the urethra (water pipe) into the bladder. Men should try to relax and imagine they are passing urine. This allows the ‘valves’ to open and makes the procedure more comfortable. The doctor will look carefully at the lining of the urethra and bladder. Sterile water is passed down a side channel in the flexible cystoscope to slowly fill your bladder. This makes it easier for the doctor to see the lining of the bladder. As your bladder fills you may feel the urge to pass urine, but this is rarely uncomfortable.

A cystoscopy takes a few minutes if it is to just look inside the bladder, although you should allow at least 1 to 2 hours in hospital for everything to be completed. It may last longer if the doctor does an additional procedure, for example, take a biopsy (small sample) from the lining of the bladder. If a JJ stent is going to be removed, the procedure may take a little longer. This is also removed with the aid of a small grasping instrument passed through the side channel of the flexible cystoscope. After everything has been completed, the cystoscope is then gently pulled out. This is quick and painless. Your doctor may tell you what they saw inside your bladder straight after the test. If you had a biopsy taken, the sample is sent away to be tested and looked at under a microscope. It can take several days for the report of the biopsy to come back to the doctor.

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What to expect afterwards?

As the bladder will be full of water, it will probably be necessary to pass urine again once the procedure is finished. Most people feel ready to go home after a short rest. Once home, it's sensible to take it easy for the rest of the day. Most people feel able to resume normal activities on the following day.

It is normal to have some bladder spasm after a cystoscopy. This may cause a feeling of urgency or have to go to the toilet all the time. In addition, there may be some stinging when you pass urine for a day or two after this procedure. Also, the urine may look pink due to mild bleeding, particularly if a biopsy was taken or a JJ stent was removed.

You will usually be asked to take antibiotics for a few days after the procedure to reduce the chance of a urinary infection. Please let your doctor know if you have allergies to medication.

For the next 24 hours you may have a mild burning feeling when you pass urine, and feel the need to go more often than usual.

Drinking plenty of water can prevent the development of infection or inflammation. The recommended amount is about three litres of water over the course of 24 hours, with the intake evenly spaced out. If blood is present in the urine, drinking a little extra water and resting for an hour or two will usually settle things down.

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Are there any side-effects or complications?

Most flexible cystoscopies are performed without any problem. Occasionally, a urine infection develops shortly after a flexible cystoscopy. This can cause a fever (high temperature) and pain when you pass urine. There may be bleeding especially if a biopsy has been taken or if a JJ stent has been removed.

After you have had a cystoscopy, tell your doctor if:

• pain or bleeding is severe.
• any pain or bleeding lasts longer than two days.
• you develop symptoms of infection (fevers, offensive smelling urine, the need to pass urine frequently with significant discomfort)

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Are there alternatives to flexible cystoscopy?

The cystoscopy can be performed using a rigid instrument under general anaesthetic. This is painless at the time of the procedure, but has similar side-effects afterwards. A greater range of procedures can be performed through a rigid cystoscope compared to a flexible cystoscope. Sometimes, it maybe necessary to perform a rigid cystoscopy after a flexible cystoscopy.

Tests such as ultrasound, IVU (intravenous urogram), CT and MRI do not show the lining of the interior of the bladder well enough to allow an accurate diagnosis of the problems affecting the bladder. A flexible cystoscopy is almost always necessary to diagnose bladder or prostate problems.

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