Cystoscopy

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As with many other medical tests, your main anxieties before as flexible cystoscopy will be due to a fear of the unknown. The purpose of this leaflet is to tell you what to expect so that you need have no such worries.

What is a cystoscopy?

The term cystoscopy comes from the Greek "cysto" for bladder and "scopy" meaning to loo. Modern, advanced techniques ensure flexible cystoscopy is simple, quick and painless.

To understand cystoscopy it helps to look at the parts of the urinary system (waterworks).

The bladder is a muscular bag which, when full, is about the size of a grapefruit. It stores urine which reaches it through the ureters (the tubes which connect the kidneys to the bladder). When the time comes to pass water, the muscle wall squeezes the urine out into the waterpipe or urethra. In women, the urethra is only about an inch long. In men, it is much longer and follows an S-shaped course from the bladder outlet, where it passes through the prostate gland, and down to the end of the penis. Both men and women have muscular valves called sphincters, which control the flow of urine. A woman’s sphincter muscle lies around most of her short urethra while in the man the main sphincter is just below the prostate gland.

When you have a cystoscopy, a tube containing a miniature telescope is passed down the urethra so that the doctor can examine the inside of the bladder. It is usual to look at the urethra itself so the correct term "cystourethroscopy" is also used for the examination.

Why flexible cystoscopy?

The older telescopes used for cystoscopy are straight metal tubes containing tiny glass lenses. A general anaesthetic is often necessary to pass these instruments into the bladder, especially in men, where the natural curves of the urethra need to be straightened. A rigid instrument and general anaesthetic is necessary when the cystoscope is used to perform operations within the prostate and bladder, for instance, transurethral resection (TUR).

The lenses at each end of a flexible cystoscope are connected by a bundle of tiny glass fibres, which allows the telescope to bend freely. The flexible cystoscope adjusts itself to fit the curving male urethra. This allows it to pass through painlessly, avoiding the need for a general anaesthetic. The examination can be done with the patient lying flat, in a comfortable position.

Flexible cystoscopy is usually done in the outpatient clinic, which is convenient for the patient and cost-effective for the Health Service.

Why do I need a cystoscopy?

Some urinary symptoms are due to problems in the bladder or the urethra. Sometimes the cause will be clear from x-rays or tests of the blood or urine, but often the only way your doctor can be sure what is going on is to take a look inside with a cystoscope.

How do I prepare for my flexible cystoscopy?

No special preparation is required at all. This means that on the day of the investigation you can eat and drink as normal. You simply turn up for your appointment, have your cystoscopy and then leave the clinic under your own steam. There is no need to rest afterwards.

Occasionally, the doctor may want to give an injection to relax a particularly apprehensive patient. It is unsafe to drive after this type of injection, so do take a friend along with you to give you moral support and to be able to take you home afterwards if necessary.

When you get to the clinic you will usually be asked to change into a hospital gown. This is to stop your clothes getting wet during the procedure. You will then be asked to empty your bladder. The nurses will give you a container and instructions if a urine specimen is to be provided.

Although you do not need a general anaesthetic for flexible cystoscopy, the urethra needs to be prepared with anaesthetic jelly, this being squeezed gently into it from a tube or syringe. The jelly numbs the urethra and lubricates it. It may also contain an antiseptic.

The local anaesthetic jelly takes at least five minutes to work – men may be asked to stop the jelly escaping after it goes in by gently squeezing the tip of the penis for a minute or so.

When the jelly has had time to work, it is time for the flexible cystoscopy.

What does the flexible cystoscopy involve?

The doctor will clean the genitals with a mild disinfectant and then surround the area with a paper sheet. Try not to touch it with your hands.

The flexible cystoscopy is taken from the chemical used to disinfect it and carefully wash in sterile water. Don’t be alarmed at the sight of it – only the flexible tip goes inside your bladder! The doctor then gently inserts the tip of the instrument into the urethra. If you are lucky, he will give you a commentary about what he sees as the instrument goes into the bladder.

Men may be asked by the doctor to try and pass urine when the instrument reaches the sphincter below the prostate gland. In trying to pass urine the sphincter naturally relaxes and the cystoscopy can pass through more easily. Don’t worry, no urine will actually come out while the cystoscope is in the urethra. There may be momentary stinging as the sphincter opens.

The flexible cystoscope has a control device, which allows the doctor to steer it by bending its tip. Once the end of the instrument is in the bladder, twisting the instrument and steering it in this way brings the whole of the lining into view.

When the bladder is empty, there are folds in the lining. Saline or slat water is run into the bladder through the cystoscope to stretch out these folds and fill the bladder. This way the whole of the lining can be seen. It is therefore natural at the end of the examination to feel as if you need to pass water again.

It is usual for a nurse to stay with you throughout the examination, which is very quick. You may experience some slight discomfort, but it will not last long.

Is the flexible cystoscope used only to examine the bladder?

Because you are awake, only painless operations can be done during flexible cystoscopy. Often the flexible cystoscope will only be used to look; if something more needs to be done, you will be asked to come back. However, it is possible to take specimens (biopsies) from the lining of the bladder without discomfort. Tubes or fine catheters may be passed into the ureters to take x-rays of the kidneys (retrogade ureterograms). In specialized centres, they may even be able to operate painlessly on small bladder growths by using laser.

What are the after-effects of flexible cystoscopy?

Most patients have no trouble after a flexible cystoscopy. A mild burning on passing urine usually gets better after a day or so. Drinking extra water can help. A little bleeding is common especially if a biopsy specimen has been taken. An occasional problem after flexible cystoscopy is a water infection. If you have a temperature, pain, persistent burning or bleeding contact your doctor.

Finally...

Relax and listen to what the doctor tells you. There are advantages to being awake for your cystoscopy. If you are getting more discomfort than you think you should have, tell the doctor. If you have any questions, ask them. Having a flexible cystoscopy may not be exactly enjoyable but you may well find it interesting and instructive. You can expect to be told the result of your examination straight away.