Indications^1–5

• Surveillance for bladder and urethral malignancies

• Evaluation of macroscopic/microscopic hematuria, voiding symptoms, urethral/bladder fistulae, congenital anomalies

• Diagnosis of urethral/bladder neck stricture

• Urethral assessment for diverticular disease (women)

• Ureteral stent removal

• Intraoperative evaluation to facilitate ureteroscopy and following incontinence or prolapse procedures

Preoperative Preparation

• Equipment:

  • Flexible cystoscope, irrigation tubing, light source, and video/camera system (for fiber optic endoscopes, the physician can place his/her eye on the eyepiece and forego the video/camera system—this is not an option with the digital flexible cystoscope) (Figs. 1–2)

  • Distention/Irrigation media: 1 L normal saline (Fig. 3)

  • 2% lidocaine jelly in a prefilled disposable syringe for urethral instillation

  • Surgical lubricant (Fig. 4)

  • Povidone–iodine solution and sponges for surgical preparation of the urethral meatus and, in males, the phallus and in women, the vulva (Fig. 4)

  • Sterile gloves (Fig. 4)

  • O.R. towels to drape the field (Fig. 4)

  • Grasping forceps (if performing stent removal)

• Other considerations:

  • Option: Antibiotic prophylaxis (single dose of TMP-SMX or fluoroquinolone) in patients with impaired natural defense mechanisms (advanced age, immunodeficiency, etc.) or those with increased local bacterial concentrations (externalized catheters, recent hospitalization, etc.)

  • Patient should empty his/her bladder before the procedure; a urine specimen should be collected for analysis—if bacteriuria is present the procedure should be postponed

• Patient is positioned on the examination table (Fig. 5)

  • Cleanse the penis/vulva and around the urethral meatus, in a sterile manner

    • Pour the povidone–iodine solution over the sponges

    • Using an individual sponge once each, clean the area three times

  • Using the O.R. towels, drape the thighs, and lower abdomen of the patient

  • Subsequently, introduce 2% lidocaine jelly into the urethra for 5 to 10 minutes before the cystoscopic procedure

  • Cover the patient's penis/vulva with an additional O.R. towel until beginning the cystoscopic procedure to ensure privacy

Patient Positioning

• Supine (males and females) or frog-leg supine (females)

Surgical Steps^3,5

Male-specific (Fig. 6)

• Lubricate the bending portion of the cystoscope with surgical lubricant

• Insert the distal tip of the cystoscope into the urethral meatus and advance while visualizing the urethra on the video monitor

• After passing the fossa navicularis, allow the irrigation medium to flow

• With the left hand, hold the penis and straighten it to create a near-90° angle with the abdominal wall

  • This will straighten the urethra, and will allow easier passage of the cystoscope to the level of the external sphincter

• Identify the external urethral sphincter and ask the patient to relax the sphincter (i.e., attempt to void) before advancing the cystoscope

  • The assistant can squeeze the irrigant bag at this point to provide for a more forceful stream of irrigant to aid passage of the endoscope across the sphincter

• Identify the verumontanum, lobes of the prostate, and then the bladder neck

  • Do not evaluate the prostate for the degree of possible obstruction at this time

• Once the distal tip is past the bladder neck, turn off the flow of the irrigation fluid if the bladder appears to be adequately distended.

  • Avoid overdistention of the bladder as this may cause patient discomfort

• Begin the inspection of the bladder at the 12 o'clock position, which corresponds to the dome of the bladder

  • An air bubble floating along the anterior wall of the bladder can help identify the 12 o'clock position

• Withdraw the cystoscope enough to see the bladder neck, and then advance again while beginning the inspection at the 1 o'clock position taking in the entire arc of the bladder from the posterior wall to the bladder neck.

• At the bladder neck, the examiner can rotate his/her wrist by 30 degrees, clockwise, to the 1 o'clock position and carefully visualize the left lateral anterior surface of the bladder until reaching the back wall of the bladder. The endoscope is then rotated another 30 degrees and the 2 o'clock arc is examined as the endoscope is pulled toward the bladder neck, and then by rotating the wrist another 30 degrees clockwise to the 3 o'clock position the endoscope is advanced from the bladder neck to the back wall of the bladder as that area of the lateral wall of the bladder is examined.

• Return to the 12 o'clock position

• The examiner's wrist is then rotated 30 degrees counterclockwise and the arc of the bladder at the 11 o'clock position is examined as the endoscope is withdrawn to the bladder neck. The endoscope is then rotated another 30 degrees counterclockwise and the 10 o'clock arc is examined as the endoscope is advanced toward the back wall of the bladder, and then by rotating the wrist another 30 degrees counterclockwise to the 9 o'clock position the endoscope is advanced from the bladder neck to the withdrawn toward the bladder neck as that area of the lateral wall of the bladder is examined.

• Return to the 12 o'clock position

• Withdraw the cystoscope toward the bladder neck and deflect the endoscope downward toward 6 o'clock (i.e., the floor of the bladder)

  • Identify the interureteral ridge at 6 o'clock, follow the ridge to the right to visualize the right ureteral orifice, and then follow the ridge to the left to visualize the left ureteral orifice as well as the expanse of the bladder between 4 and 8 o'clock

• Return to the 12 o'clock position

• Advance the cystoscope and completely retroflex the cystoscope from this position to inspect the bladder neck

  • The examiner's wrist is then rotated both clockwise and counterclockwise with the endoscope retroflexed to fully inspect the bladder neck and assess for the presence of a prostatic median lobe

• To complete the examination, straighten and withdraw the cystoscope slowly with irrigant flowing

  • Inspect the lateral lobes of the prostate and assess the length of the prostatic urethra; make note of whether the prostate is obstructing

Female-specific (Fig. 7)

• Lubricate the bending portion of the cystoscope with surgical lubricant

• Have your assistant or nurse hold the body of the cystoscope.

• With the nondominant hand spread the labia, and with the other hand gently insert the illuminated distal tip of the cystoscope into the urethral meatus and advance the endoscope into the bladder.

• Turn on the irrigant

• Allow the irrigation fluid to fill the bladder and then turn it off to not cause any patient discomfort

• Repeat the process of examining the bladder as described for the male patient.

• To complete the examination, straighten and withdraw the cystoscope while inspecting the urethra. If there is concern for a urethral diverticulum, a finger can be placed into the vaginal vault to massage the posterior urethral wall as the cystoscope is withdrawn, thereby calling attention to the expulsion of any fluid contained within the diverticulum and directing the examiner toward the opening of the diverticulum.

N.B.: In a patient with a history of bladder cancer, one can attach a 30-cc syringe to the endoscope and urine for cytology can be collected by barbotage, by gently instilling fluid aimed at the bladder wall and then withdrawing irrigant fluid; this can be done several times following which the fluid in the syringe is sent along with the voided urine for cytologic evaluation.

Postoperative Care⁶

Office-based cystoscopy is a well-tolerated procedure and does not require special postprocedural care. The bladder will be full with the irrigant fluid, and therefore the patient should void after the procedure, before leaving the office. Patients may experience some transient irritative urinary symptoms; these often resolve within 24 to 48 hours. In our office, we routinely give one tablet of an antibiotic at the end of the procedure, usually ciprofloxacin 500 mg.

Troubleshooting⁵

A cystoscopy on a patient with a newly discovered urethral stricture is best terminated so formal urethrography can be done to clearly delineate the stricture in its nascent condition. On rare occasions, if the narrowing is minimal, then one might consider urethral dilation; however, this may not be easily done in the office and might require an outpatient cystoscopy under intravenous sedation. Similarly, patients with a low pain tolerance will need intravenous sedation and thus require cystoscopy in an outpatient surgical center. If the preliminary urinalysis reveals bacteriuria, the cystoscopy should be delayed until appropriate antibiotic therapy has been given to the patient and the urinalysis/urine culture is within normal limits/sterile. Finally, if the patient has macroscopic hematuria, one might consider placing a three-way Foley catheter and irrigating the bladder until the return of the effluent is clear, following which flexible cystoscopy can be undertaken. This will provide the examiner with a better chance of identifying the source of the bleeding.

Additional thoughts: Flexible cystoscopy provides the urologist with the ability to perform cystoscopy under a variety of conditions and environments. As such it can be performed in a hospital bed or for male patients, with them in a wheelchair.⁷

Supplementary Videos

Click here for Supplementary Videos: Bladder Exam_Female.mp4; Bladder Exam_Male.mp4; Cystoscope Withdrawal & Urethral Inspection_Female.mp4; Draping & Prep_Female.mp4; Draping & Prep_Male.mp4; Equiptment & Room Preparation.mp4; Full Video_Female.mp4; Full Video_Male.mp4; Withdrawal & Urethral Inspection_Male.mp4

Author Disclosure Statement

No competing financial interests exist.