Lidocaine 2% Gel Versus Plain Lubricating Gel for Pain Reduction During Flexible Cystoscopy: A Meta-Analysis of Prospective, Randomized, Controlled Trials

Noninvasive studies may have potential to replace cystoscopy in non-muscle invasive bladder cancer follow-up

Bladder cancer has a high recurrence rate which requires frequent follow-up. Cystoscopy is currently the gold standard for follow-up which is invasive and undesirable procedure for patients. We aimed to investigate the feasibility of noninvasive studies for follow-up of non-muscle invasive bladder cancer. This retrospective study was done for non-muscle invasive bladder cancer patients with abnormal lesion at follow up cystoscopy, therefore those needed transurethral resection of bladder tumor (TUR-BT). Inclusion criteria was patients who had preoperative bladder magnetic resonance imaging (MRI) within 1 month to TUR-BT and urine cytology results. MRI, urine cytology, and surgical pathology results were analyzed for sensitivity, specificity, positive and negative predictive values, accuracy, diagnostic odds ratio, and number needed to misdiagnose for the diagnostic performance of non-invasive studies. From total of 2,258 TUR-BT cases, 1,532 cases of primary TUR-BT and 481 cases which bladder MRI were not done was excluded. Finally, 245 cases of TUR-BT were included. Combined urine cytology and bladder MRI showed 96% sensitivity, 43% specificity, 89% positive and 67% negative predictive values, 87% accuracy, 16.2 diagnostic odds ratio, and 7.4 number needed to misdiagnose values. Among nine false-negative cases, three (1.2%) were missed by the radiologist, two (0.8%) had an empty bladder during magnetic resonance imaging, and three (1.2%) had gross hematuria which needed cystoscopy despite of bladder MRI or urine cytology result. Only one case (0.4%) was missed based on symptoms and noninvasive tests. However, none of the false-negative cases showed rapid extensive progression requiring radical or partial cystectomy. The combination of bladder MRI and urine cytology was comparable to cystoscopy for the follow-up of recurred lesions in non-muscle invasive bladder cancer patients for sensitivity, but not for specificity. However, it may reduce the need for cystoscopy and allowing patients to have choices for follow up diagnostic methods. Also, additional imaging tests to evaluate kidney, ureter and peri-vesical lesions can be reduced.

Pain reduction methods during transurethral cystoscopy

Transurethral cystoscopy (CS) is a common urological procedure, performed mostly for diagnostic but also for therapeutic purposes. Although CS is generally well tolerated, some patients describe the pain related to the procedure as high or even “unbearable”. As a result, many patients fear and avoid both primary and/or follow-up cystoscopies. This may lead to uncontrolled progression of neoplastic disease. Therefore, it is crucial to maximally increase the comfort of the patient and to implement safe and effective analgesia before the procedure. Providing the patients with appropriate care during CS can encourage them to comply with diagnostic schedules and improve their prognosis. The aim of this review is to analyze the available literature on various methods of pain reduction during transurethral CS. The PubMed electronic database limited to English articles published until January 2021 was used in the process. Meta-analyses, systematic reviews, randomized controlled trials, clinical trials, prospective randomized studies, multicenter comparisons, reviews and retrospective comparisons were used. As a result, 65 articles were included in this review.

Lidocaine lubricant jelly does not reduce pain perception during female urethral catheterization: A systematic review with meta-analysis and trial sequential analysis

OBJECTIVE

The use of lubrication before performing urethral catheterization has been recommended. However, the benefit of using lidocaine gel over plain lubricant gel in reducing pain perception during female urethral catheterization is unclear. With this review, we aimed to compare the pain perception during female urethral catheterization with or without lidocaine lubricant gel.

METHODS

In this study, we systematically searched PubMed, Scopus, Embase, and Web of Science to identify randomized controlled trials (RCTs) comparing 2% lidocaine gel and plain lubricant gel in reducing pain perception during female catheterization. Standard Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed while conducting this review (CRD42020207312).

RESULTS

In this review, six RCTs with 464 participants were included. The overall risk of bias for these studies was low. Pain score was presented as standard mean difference (SMD) with a 95% confidence interval (CI). In the overall and subgroup analysis (according to types of pain scores) no significant difference was found between the use of lidocaine and plain lubricant jelly (SMD -0.24 95% CI [-0.96 0.47]). On trial sequential analysis (TSA), by setting alpha = 5% and beta = 20% for moderate evidence the information size calculated was 440 participants. The cumulative Z-score crossed the TSA line proving the reliability of the results. According to Grading of Recommendations Assessment, Development and Evaluation, the evidence is "moderately" certain.

CONCLUSION

The use of 2% lidocaine gel in female catheterization does not provide a significant reduction in pain perception as compared to plain lubricant gel.

Alternating Cystoscopy with Bladder EpiCheck® in the Surveillance of Low-Grade Intermediate-Risk NMIBC: A Cost Comparison Model

BACKGROUND

Bladder cancer surveillance is invasive, intensive and costly. Patients with low grade intermediate risk non-muscle invasive bladder cancer (NMIBC) are at high risk of recurrence.

OBJECTIVE

The objective of this model is to compare the cost of a strategy to alternate surveillance with cystoscopy and a urine marker, Bladder EpiCheck, to standard surveillance.

METHODS

A decision tree model was built using TreeAge Pro Healthcare to compare standard surveillance (Standard) with a modified surveillance incorporating Bladder EpiCheck. The model was based on 2 years of surveillance. Outcomes were obtained from literature. Costs were obtained from US and 9 European countries. Sensitivity analyses were performed.

RESULTS

The efficacy of the model was equivalent in terms of recurrence for each arm with median recurrence rate of 22%. When setting marker price at 200 local currency, the marker arm was less expensive in the USA, Netherlands, Switzerland, Belgium, Italy, Austria and UK by 154€ to 329£ per patient, for a 2-year period. Cost was higher in France, Spain, and Germany by 33-103€. Cost parity was achieved with marker price between 148€ and $421. Marker cost and specificity have the greatest impact on the overall model cost.

CONCLUSIONS

A strategy alternating the urine marker Bladder EpiCheck with cystoscopy in the surveillance of patients with low grade intermediate risk bladder cancer is cost equivalent in the US and European countries when the marker is priced 148€ -$421, as a result of the marker's high specificity (86%). Prospective studies will be necessary to validate these findings.

Dorsal penile nerve block alleviates pain in men undergoing rigid cystoscopy: A single‐center, randomized, double‐blind, and placebo‐controlled trial

Objective

To assess the effectiveness and safety of dorsal penile nerve block (DPNB) compared with tetracaine gel in analgesia for men undergoing rigid cystoscopy.

Patients and methods

This study was conducted as a prospective, randomized, double‐blind, placebo‐controlled, and single‐center trial. Men undergoing diagnostic rigid cystoscopy were randomly allocated into one of three groups (n = 86 each): (1) tetracaine gel group (DPNB with saline), (2) DPNB group (DPNB with ropivacaine + plain lubricant), and (3) combination group (DPNB with ropivacaine + tetracaine gel). The primary outcome was visual analog scale (VAS) for pain at cystoscopic inspection of the external sphincter.

Results

VAS (median [interquartile]) at inspection of the external sphincter was significantly lower in both DPNB and combination groups than that in tetracaine gel group (4 [3–6] and 4 [3–5] vs 6 [5–7], P < .0001), with a 33% reduction of median VAS. Overall pain level during procedure was significantly alleviated in the DPNB and combination groups with more stabilized HR and MAP when compared with tetracaine gel group. No adverse events were observed during DPNB including penile hematoma, erection, local anesthetic toxicosis or incompletion of cystoscopy.

Conclusion

Our study suggests analgesia provided by DPNB with or without tetracaine gel instilled is superior to that provided by tetracaine gel alone in men undergoing diagnostic rigid cystoscopy.

Clinical Trials Registration

ClinicalTrials.gov registration number: NCT02502487.

Does instillation of lidocaine gel following flexible cystoscopy decrease the severity of post procedure symptoms? A randomised controlled trial assessing the efficacy of lidocaine gel post flexible cystoscopy

Objective

To assess whether instillation of lidocaine gel both before and after flexible cystoscopy is more effective at reducing post procedural symptoms than instillation of lidocaine gel pre flexible cystoscopy alone. We hypothesise that inadequate urethral dwell time and dilution of lidocaine gel by the irrigation fluid during flexible cystoscopy limits its anaesthetic efficacy. Only one other study has attempted to reduce bothersome urinary symptoms through an intervention after flexible cystoscopy.

Methods

This was a randomised controlled trial in which patients were randomised 1:1 to receive lidocaine gel pre and post flexible cystoscopy (treatment) or lidocaine gel pre flexible cystoscopy only (control). Patient-reported outcome measures were used to assess symptoms and quality of life prior to cystoscopy, on day 2 and day 7 post cystoscopy.

Result

Fifty patients were divided equally between the treatment and control groups. There were no significant differences in baseline characteristics between the groups (p = 1.000). An overall symptoms variable was measured, though no significant difference was found in the distribution of responses between the groups at baseline, 2 or 7 days after the flexible cystoscopy (p = 0.423, 0.651,0.735). In the treatment group, 1 patient (4.0%) presented to a doctor for review following flexible cystoscopy, and 4 patients (16.0%) presented in the control group (p = 0.349).

Conclusion

Initial study results suggest that post-operative lidocaine does not significantly limit the exacerbation of urinary symptoms following flexible cystoscopy; however, our results are not powered to detect a small difference. We do not recommend a change in practice based on our results.

Efficacy of urination in alleviating man's urethral pain associated with flexible cystoscopy: a single-center randomized trial

BACKGROUND

This study aimed to assess whether urethral pain can be alleviated by urination in male patients undergoing flexible cystoscopy.

METHODS

Ninety-six male outpatients undergoing flexible cystoscopy were randomly divided into two groups. Patients in the test group urinated during flexible cystoscopy, whilst patients in the control group received no instructions to do so. All patients received 10 mL of 2% lidocaine gel prior to assessment. Using 0 (no-pain) to 10 (unbearable severe pain) pain scores (VAS), we assessed patient discomfort prior to anesthesia gel perfusion (baseline), during gel perfusion, during cystoscope insertion through the urethra, and 15 min post-examination analysis. The entire protocol was completed by a single doctor in our Department of Urology.

RESULTS

The groups showed no statistical differences regarding age or examination time. During cystoscope insertion, the test group recorded significantly lower pain scores 2 (IQR 1-3) - compared to the control group 3 (IQR 2-3), (P = 0.001). No significant differences between other evaluation points were observed between groups.

CONCLUSION

Urethral pain can be significantly alleviated by urination in male patients undergoing flexible cystoscopy through the urethra.

TRIAL REGISTRATION

Registry name: Clinical study of urination action to relieve urethral pain associated with flexible cystoscopy. Registration number: ChiCTR-INR-17013294 Date of Registration: 2017-11-08.

Pain and anxiety assessment during cystourethroscopy in males using voiding instruction: A prospective, randomized controlled study

Introduction

Office cystourethroscopy is one of the common and most frequent urological procedures. Pain and anxiety during the procedure might lead to noncompliance and incomplete cystoscopic examination. Negotiating cystoscope through external sphincter is the most painful and uncomfortable distressing part of cystoscopy. To overcome this, manual compression of irrigation bag during cystoscopy has been used and found to be helpful. Numerous other methods were also studied. Despite these, cystoscopy is still painful and causes anxiety in patients. External sphincter gets relaxed naturally during the act of micturition. Based on this principle, pain and anxiety were studied with voiding instruction during cystourethroscopy.

Objective

To study the effect of voiding instruction on anxiety and pain during cystourethroscopy using the Hamilton Anxiety Rating Scale (HAM-A) and visual analogue scale (VAS), in a well-matched Eastern Indian male patient population in a prospective, randomized pattern.

Methods

A total of 100 male patients were recruited from those who underwent cystourethroscopy examination in SSKM Hospital and were prospectively randomized into two groups: cystoscopy with or without voiding instruction. Pre- and postprocedure HAM-A score and postprocedure VAS score were recorded.

Results

The mean postprocedural pain (VAS) score between voiding instructed and noninstructed groups reached statistical significance: 3.06 ± 1.98 (Range, 2-5) and 5.16 ± 2.86 (Range, 4-8), respectively (P < 0.001). Preprocedure HAM-A score was similar between both groups. Postprocedure median HAM-A score was statistically significantly lower (mean 17.86 ± 2.8 vs. 19.76 ± 3.12; P < 0.001) in voiding instructed group.

Conclusion

Pain and anxiety level during cystourethroscopy examination in males can be significantly reduced when the patient is instructed to void during cystourethroscopy examination.

Cystoscopy Real-Time Self-Visualization and Its Impact in Patient's Pain Perception

OBJECTIVES

To determine if self-visualization of ambulatory cystoscopy provides a decrease in pain perception in male and female patients.

METHODS

A quasi-randomized controlled trial involving patients scheduled for ambulatory cystoscopy from August to November 2017. The indications were: hematuria, bladder cancer surveillance, lower urinary tract symptoms, and incontinence. The patients were quasi-randomized into two groups by scheduled date. Both groups received the same explanation before and during cystoscopy. The variables analyzed were gender, age, Visual Analog Scale (VAS) score, number of previous cystoscopies, and indication and positivity of the test for bladder neoplasia. All patients were analyzed by group and gender separately. The statistical tests used were: Wilcoxon rank-sum, Kruskal-Wallis, Mann-Whitney U test, Pearson correlation, and linear regression.

RESULTS

Four hundred four patients were included (318 males and 86 females) and divided into two groups, group A (no self-visualization, n = 239) and group B (self-visualization, n = 165). In males, mean VAS score was 2.6 for group A and 2.5 for group B (p = 0.276); in females, VAS score was 2.78 for group A and 1.64 for group B (p = 0.008). Regarding the remaining variables analyzed, neither positivity of the test for neoplasia (p = 0.14) nor cystoscopy indication (p = 0.597) had any influence. In patients with two or more previous cystoscopies, a reduction in mean VAS score was seen in both genders. In males having their first cystoscopy the mean VAS score was 3.1 and decreased to 2.1 for the third or more (p = 0.001); in females the mean VAS score was 2.89 for the first and 1.56 for the third or more (p = 0.02), although this benefit tended to disappear when the number of previous cystoscopies was taken into account.

CONCLUSION

In male patients, self-visualization of cystoscopy did not impact pain perception, while in female patients, it seemed to provide a benefit. The number of previous cystoscopies had an influence, diminishing the perception of pain, regardless of whether the patient visualized the procedure or not.

Distraction during cystoscopy to reduce pain and increase satisfaction: Randomized control study between real-time visualization versus listening to music versus combined music and real-time visualization

Purpose:

This study aims to compare the various distraction methods used during office cystoscopy to decrease pain and dissatisfaction among patients.

Materials and Methods:

Two hundred patients undergoing rigid cystoscopy between January 2017 and July 2017 were randomized into four groups of 50 patients: (1) Group I: Patients who listened to music during the cystoscopy, (2) Group II: Patients allowed real-time visualization of the cystoscopy, (3) Group III: Patients who listened to music and had real-time visualization of the procedure, (4) Group IV: Control group undergoing cystoscopy without any distraction used. A visual analog scale (VAS) (1–10) was used for a self-assessment of pain, satisfaction, and willingness for repeat cystoscopy.

Results:

Demographic characteristics, mean age, procedure duration, and procedure indications were statistically similar between the four groups. The mean VAS pain score were significantly lower in the three study Groups (I, II, and III) where distraction methods were used during cystoscopies as compared to the control Group IV (P < 0.001) and the satisfaction VAS scores and VAS scores for willingness to undergo a repeat procedure were significantly higher in the study groups (P < 0.001). Statistically significant decreased postprocedural pulse rate and blood pressure in comparison with to their preprocedural values were observed when distraction methods were used (P < 0.01). Patients undergoing cystoscopies listening to music and real-time visualization (Group III) had better VAS scores than the others (P < 0.01).

Conclusions:

Distraction methods reduce pain and increase satisfaction among patients. Best results are with combined listening to music and direct real-time visualization.

Office stent placement under local anesthesia is a safe and efficient procedure for the management of multiple ureteral disorders

OBJECTIVE

To assess the outcomes of ureteral stent placement under local anesthesia for the management of multiple ureteral disorders.

METHODS

Retrospective study of 45 consecutive ureteral stents placed under local anesthesia from January 2015 to July 2016. Inclusion criteria were hemodynamically stable patients with urinary obstruction, urinary fistula or for prophylactic ureteral localization during surgery. Five minutes before the procedure, 10ml of lidocaine gel and 50ml of lidocaine solution were instilled in the bladder. A 4.8Fr ureteral stent was placed using a 15.5Fr flexible cystoscope under fluoroscopic control. Characteristics of procedures and outcomes were analysed.

RESULTS

A total of 45 procedures (33 placement, 12 replacements) were attempted in 37 patients, of which 40 (89%) were successful. There were 10 male (27%) and 27 female patients (73%) with a mean age of 58.6 years (±17.5). Main indications for stent placement were stones (37.8%), extrinsic ureteral compression (28.9%) and surgery ureteral localization (22.2%). The reasons for failing to complete a procedure were the inability to pass the guidewire/stent in 4 cases (8.8%) or to identify the ureteral orifice in 1 (2.2%). Postoperative complications occurred in 8 patients (17.8%) (7 Clavien I, 1 Clavien IIIa). No procedure was prematurely terminated due to pain. Statistical analysis did not find significant successful predictors. The outpatient setting provided a fourfold cost decrease.

CONCLUSIONS

Ureteral stent placement can be safely and effectively performed under local anesthesia in the office cystoscopy room. This procedure could free operating room time, reduce costs and minimize side effects of general anesthesia.

The Burden of Cystoscopic Bladder Cancer Surveillance: Anxiety, Discomfort, and Patient Preferences for Decision Making

OBJECTIVE

To examine discomfort, anxiety, and preferences for decision making in patients undergoing surveillance cystoscopy for non-muscle-invasive bladder cancer (NMIBC).

METHODS

Veterans with a prior diagnosis of NMIBC completed validated survey instruments assessing procedural discomfort, worry, and satisfaction, and were invited to participate in semistructured focus groups about their experience and desire to be involved in surveillance decision making. Focus group transcripts were analyzed qualitatively, using (1) systematic iterative coding, (2) triangulation involving multiple perspectives from urologists and an implementation scientist, and (3) searching and accounting for disconfirming evidence.

RESULTS

Twelve patients participated in 3 focus groups. Median number of lifetime cystoscopy procedures was 6.5 (interquartile range 4-10). Based on survey responses, two-thirds of participants (64%) experienced some degree of procedural discomfort or worry, and all participants reported improvement in at least 2 dimensions of overall well-being following cystoscopy. Qualitative analysis of the focus groups indicated that participants experience preprocedural anxiety and worry about their disease. Although many participants did not perceive themselves as having a defined role in decision making surrounding their surveillance care, their preferences to be involved in decision making varied widely, ranging from acceptance of the physician's recommendation, to uncertainty, to dissatisfaction with not being involved more in determining the intensity of surveillance care.

CONCLUSION

Many patients with NMIBC experience discomfort, anxiety, and worry related to disease progression and not only cystoscopy. Although some patients are content to defer surveillance decisions to their physicians, others prefer to be more involved. Future work should focus on defining patient-centered approaches to surveillance decision making.

Anaesthesia of the posterior urethra and pain reduction during cystoscopy - a randomized controlled trial

Introduction

Standard intra-urethral instillation of anaesthetic gel may not sufficiently exclude pain perception during cystoscopy.

Aim

To evaluate the impact of the anaesthesia within the posterior urethra on pain intensity related to cystoscopy in men.

Material and methods

One hundred and twenty-seven men undergoing cystoscopy were prospectively enrolled in the study. Patients were randomly assigned to the experimental or control group (66 vs. 61 patients). Intra-urethral instillation of 2% lidocaine gel was done in both groups. In the experimental group, the posterior urethra was additionally anaesthetized with distribution of the lidocaine gel by catheterisation. The study endpoints were pain intensity at successive time points of the procedure assessed on a numeric rating scale, overall pain intensity assessed on a Likert scale, the need for analgesics during 6 h after the procedure, and the frequency of urinary tract infections (UTIs) during 14 days after the procedure.

Results

Pain perception during cystoscopy did not differ significantly between the two groups (p > 0.05). However, after 6 h patients in the experimental group were more likely to declare that the cystoscopy was painless (81.8% vs. 70.2%, relative risk = 1.17). The need for analgesics and the incidence of UTI were similar in both groups (p > 0.05). Statistically significant differences regarding pain perception were observed depending on patients’ age and the number of transurethral procedures performed in the past, with no relation to type of anaesthesia (p < 0.05).

Conclusions

Anaesthesia of the posterior urethra is not more efficacious in reducing pain related to cystoscopy than standard instillation of anaesthetic gel. However, it improves the general perception of the procedure, and hence may positively influence patients’ compliance.

Effect of diclofenac suppository on pain control during flexible cystoscopy-A randomized controlled trial

TRIAL DESIGN: To compare the difference in pain score during flexible cystoscopy between patients undergoing the procedure with plain lubricating gel  only and plain gel with diclofenac suppository in a randomized control trial.

METHODS:  A total of 60 male patients with an indication of flexible cystoscopy were enrolled in a prospective, randomized controlled study. Patients were randomized in two groups. In group “A”, patients received diclofenac suppository one hour prior to the procedure while group “B” did not receive diclofenac suppository. Both groups received 10 ml of intra-urethral  plain gel for lubrication during flexible cystoscopy. Pain score was recorded immediately after the procedure using the visual analogue scale (VAS). Pre- and post-procedure pulse rate and systolic blood pressure was also recorded. Statistical analyses were performed using chi-square test and student t-test. Regression analysis was performed to address the confounding variables.

RESULTS: Both groups were comparable for variables including age, duration of procedure, level of operating surgeon and indication of procedure. Most common indication for flexible cystoscopy was removal of double J stent. There was a statistically significant difference in the mean pain score between two groups ( p = 0.012).  The difference in post-procedure mean pulse rate in the two groups was statistically significant ( p= 0.01) however there was no difference observed in mean post procedure systolic blood pressure. Regression analysis showed that none of the confounding variables were significantly affecting pain perception.

CONCLUSIONS: Intra rectal diclofenac suppository is simple and effective pre-emptive analgesia. We recommend its routine use during flexible cystoscopy for better pain control.

Pain Associated With Urethral Catheterization Is Reduced in Males by Simultaneous Voiding Maneuver

OBJECTIVE

To assess whether urethral pain during male catheterization can be reduced if the patient is instructed to void during the insertion of the catheter.

METHODS

Ninety-six males (age 66 ± 13) who were referred for multichannel urodynamic study were prospectively randomized to 2 groups according to the catheter insertion technique: (1) patients who were instructed to void during catheterization, and (2) patients who had no guidance prior or during catheterization. Exclusion criteria were the following: use of analgesics within the previous 24 hours, active urinary tract infection, indwelling urethral catheter, pre-existing urethral pain, and known urethral stricture or inability to cooperate with pain assessment due to mental disorders. A 0 to 10 visual analog pain scale was filled in different time points: prior and immediately after instillation of the lubricant gel into the urethra, immediately after the insertion of the catheter, and 15 minutes after the test.

RESULTS

Study groups did not differ in terms of demographic, clinical, and urodynamic parameters. The median visual analog pain scale during catheterization was 2 (interquartile range 1-3) and 4 (interquartile range 3-5) in groups 1 and 2, respectively (P < .001). There were no differences in the reported scores in the other checkpoints.

CONCLUSION

Pain level during urethral cauterization in males can be significantly reduced when the patient is instructed to void during the insertion of the catheter into the urethra.

The Use of Topical Lidocaine Gel During Intermaxillary Fixation Procedure

This study aimed to validate the usefulness of lidocaine gel during intermaxillary fixation using arch bars in patients with mandible fracture by comparing 2 patient groups: one group using lidocaine gel in intermaxillary fixation and the other group undergoing traditional local infiltration.Subjects were patients with mandible fracture undergoing intermaxillary fixation using arch bars from March 2003 to February 2007. Twenty-three patients were anesthetized in the upper and lower gingiva by 2% local lidocaine solution injection; another 23 underwent topical anesthesia with 2% lidocaine hydrochloride gel applied to the upper and lower gingiva. The convenience of fixation was measured in terms of operation time and degree of pain according to the visual analog scale; arch bar loosening rate was assessed postoperatively.The mean operation times were 63 and 47 minutes in the groups undergoing local infiltration and using topical lidocaine gel, respectively. For pain degree according to the visual analog scale, the mean scores were 6.4 and 3.2 in the groups using local infiltration and topical lidocaine gel, respectively. When the arch bar loosening rate was measured postoperatively, the 2 groups differed significantly, with a rate of 26% in the group using local infiltration and 13% in the group using topical lidocaine gel.Application of topical lidocaine gel during intermaxillary fixation using arch bars in patients with mandible fracture relieves pain and offers convenience in performing the procedure. It can be a useful alternative method for patients who are sensitive to pain or have needle phobia.

Intermittent urethral catheterisation: the reality of the lubricants and catheters in the clinical practice of a Brazilian service

AIMS AND OBJECTIVES

To identify how catheters and lubricants have been used among patients using intermittent urinary catheterisation in rehabilitation.

BACKGROUND

The clean intermittent urinary catheterisation technique is an invasive procedure can cause discomfort, pain and urethral traumas. The use of lubricants and lubricated urinary catheters reduces the friction between the catheter and the urethral mucosa, minimising the risks.

DESIGN

A descriptive exploratory design was used.

METHODS

Quantitative and descriptive study developed at a rehabilitation centre of a University Hospital in the interior of the state of São Paulo, Brazil, at the Intermittent Urinary Catheterisation Outpatient Clinic, between June 2012-December 2014. After ethical approval, the data were collected through an interview with the support of a semistructured questionnaire, held during the nursing consultation. Among the users, patients using intermittent urinary catheterisation were interviewed, over 18 years of age and minors younger than eight years accompanied. Descriptive statistical analysis was applied.

RESULTS

Most of 214 (100·0%) patients were interviewed were male, single, young adults and with a primary medical diagnosis of bone marrow injury and myelomeningocele. Most patients perform the urinary catheterisation between four and six times per day. For the procedure, the majority uses polyethylene (polyvinyl chloride) catheter and, as a lubricant, 2·0% lidocaine hydrochloride on the catheter itself. Many mention lack of sensitivity when passing the catheter.

CONCLUSION

In the study sample, a risk of urethral traumas was evidenced, related to the inappropriate use of catheters and lubricants. For the patients' safety, the professionals need to acknowledge the importance of the appropriate use of lubricants and lubricated catheters to implement evidence-based practices that mobilise public policies.

RELEVANCE TO CLINICAL PRACTICE

The use of evidences demonstrates that the appropriate use of lubricants for intermittent urinary catheterisation is fundamental for patient safety and the performance of the best practices.

2% Lidocaine gel or plain lubricating gel: Which one should be used in male flexible cystoscopy?

OBJECTIVE

To investigate and compare the effects on pain of intraurethral 2% lidocaine gel and plain lubricating gel in male patients underwent flexible cystoscopy.

MATERIAL AND METHODS

The data of 220 male patients who underwent flexible cystoscopy between March 2012 and August 2014 were retrospectively analized. The patients were divided into 2 groups according to using intraurethral gel types. Group I included 120 patients who were underwent flexible cystoscopy with 2% lidocaine gel and Group II was consisted from 100 patients who underwent flexible cystoscopy with plain lubricating gel. The groups were compared according to postprocedure data including pain score, procedure time and age of patients.

RESULTS

The mean age of the patients in Group I was 50.02±11.87 years while that in Group II was 52.03±13.37 years (p=0.492). The mean procedure times were 6.02±0.787 and 6.28±0.689 minutes in Group I and Group II respectively (p=0.061). Pain perception scores were not statistically different between the groups (Group I: 3.10±0.980, Group II: 3.34±0.789, p=0.132).

CONCLUSION

Use of intraurethral 2% lidocaine gel has no advantage over plain lubricating gel in regard to pain control during flexible cystoscopy in men.

High level of patient satisfaction and comfort during diagnostic urological procedures performed by urologists and residents

OBJECTIVE

The aim of this study was to investigate how patients experience diagnostic urological procedures performed by urologists, junior residents and senior residents, and to assess the influence of procedure-related factors on patient experiences.

METHODS

Data were collected during 222 procedures: 84 transrectal ultrasound-guided prostate biopsies (TRUSP; urologists n = 39, residents n = 45) and 138 urethrocystoscopies (UCS; urologists n = 44, residents n = 94) in six hospitals. Patient experiences were assessed using a questionnaire focusing on pain, comfort and satisfaction (visual analogue scale, 0-10) and communication aspects on a four-point Likert scale. Clinical observations were made to identify influencing factors.

RESULTS

Median values for patient experiences across procedures were 10 (range 5-10) for patient satisfaction, 2 (0-9) for pain and 8 (0-10) for comfort. Generalized estimating equations revealed no significant differences between urologists, senior residents and junior residents in terms of experienced patient comfort, satisfaction or pain. Procedural time was longer for residents, but this did not correlate significantly with patient-experienced comfort (p = 0.3). In UCS, patient comfort and satisfaction were higher in the supine position for male and female patients, respectively (p < 0.01). In TRUSP, local anaesthesia resulted in a significant decrease in pain (p = 0.002) and an increase in comfort (p = 0.03). Finally, older patients experienced less pain and gave higher comfort and satisfaction responses than younger patients.

CONCLUSIONS

Patients expressed high levels of satisfaction and comfort during diagnostic urological procedures. Experiences were not affected by the level of training, suggesting highly developed interpersonal and communication skills for residents in an early stage of residency training. Patients demonstrated significant preferences for local anaesthesia in TRUSP and performance of UCS in the supine position over the lithotomy position.

Does visualisation during urethrocystoscopy provide pain relief? Results of an observational study

Background

To measure the effects of real-time visualisation during urethrocystoscopy on pain in patients who underwent ambulatory urethrocystoscopy.

Methods

An observational study was designed. From June 2012 to June 2013 patients who had ambulatory urethrocystoscopy participated in the study. In order to measure pain perception we used a numeric rating scale (NRS) 0 to 10. Additional data was collected including gender, reason for intervention, use of a rigid or a flexible instrument and whether the patient had had urethrocystoscopy before.

Results

185 patients were evaluated. 125 patients preferred to watch their urethrocystoscopy on a real-time video screen, 60 patients did not. There was no statistically relevant difference in pain perception between those patients who watched their urethrocystoscopy on a real-time video screen and those who did not (p = 0.063). However, men who were allowed to watch their flexible urethrocystoscopy experienced significantly less pain, than those who did not (p = 0.007). No such effects could be measured for rigid urethrocystoscopy (p = 0.317). Furthermore, women experienced significantly higher levels of pain during the urethrocystoscopy than men (p = 0.032).

Conclusions

Visualisation during urethrocystoscopy procedures in general does not significantly decrease pain in patients. Nevertheless, men who undergo flexible urethrocystoscopy should be offered to watch their procedure in real-time on a video screen. To make urethrocystoscopy less painful for both genders, especially for women, should be subject to further research.

Pain during Female Urethral Catheterization: Intraurethral Lubricant Injection versus Catheter Tip Lubrication--A Prospective Randomized Trial

PURPOSE

Urethral lubrication during catheterization can be performed by instilling the gel directly in the urethra or by pouring the gel on the catheter tip. In this study we compared the pain level associated with each technique during female urethral catheterization in the setup of a multichannel urodynamic study.

MATERIALS AND METHODS

A total of 94 women with a mean ± SD age of 55 ± 14 years who were referred for a multichannel urodynamic study were prospectively randomized into 2 groups according to lubrication technique, including 1) instillation of 5 ml 2% lidocaine gel in the urethra 5 minutes before catheterization or 2) lubrication of the distal part of the catheter with 5 ml 2% lidocaine gel. A visual analog pain scale of 0 to 10 was completed at different time points, including prior to gel instillation (baseline), during gel instillation (group 1), during catheterization, and 5 and 30 minutes after the procedure ended.

RESULTS

The study groups did not differ in demographic, clinical or urodynamic parameters. The mean visual analog scale score during catheterization was 2.3 ± 1.4 and 2.4 ± 1.6 in groups 1 and 2, respectively (p = 0.71). There was no difference in the reported visual analog scale score at the other checkpoints. The mean recorded visual analog scale score during instillation of the lubricant in the urethra in group 1 was 1.9 ± 0.9.

CONCLUSIONS

The actual act of lubricant instillation in the urethra during catheterization in women causes additional and unnecessary pain. Therefore, it is not recommended. Other than that there is no difference in the urethral pain level between the 2 lubrication techniques.

Is diagnostic cystoscopy painful? Analysis of 1,320 consecutive procedures

OBJECTIVE

To prospectively evaluate self-reported pain levels associated with diagnostic cystoscopy.

MATERIALS AND METHODS

Patients who underwent diagnostic cystoscopy and subsequently graded their pain level during the procedure were enrolled. Pain was graded on a Likert visual analog scale (VAS) of 1-10 where 0 = no pain and 10 = excruciating unbearable pain. Local lidocaine gel 2% was used as intraurethral lubricant.

RESULTS

Data from 1320 consecutive cystoscopies (929 males, 391 females, age range 15-93 years) between 6/2009-1/2010 were analyzed. This was the first cystoscopy for 814 patients. The overall mean VAS was 2.74 ± 1.51 (range 0-9) for rigid cystoscopy and 2.48 ± 1.53 (range 0-10) for flexible cystoscopy (P = 0.004). The reported mean pain level for first-time cystoscopy was significantly higher than that for repeat cystoscopy (2.8 ± 1.6 vs. 2.2 ± 1.4, P < 0.001), regardless of gender or type of cystoscope. Men reported significantly higher pain levels than women 2.6 ± 1.5 vs. 2.4 ± 1.4 (P < 0.04). The highest mean pain level was reported by men (3.4 ± 1.6) and women (2.5 ± 1.6) for rigid cystoscopy compared to flexible cystoscopy (2.5 ± 1.4 and 1.1 ± 1.9, respectively, P < 0.001). Pain levels > 5 were reported in 75 (5.7%) cystoscopies.

CONCLUSIONS

Cystoscopy was not associated with distressing levels of pain. Pain levels during first cystoscopies were higher than those for repeated ones. Using a flexible cystoscope is associated with a lower pain level in both men and women and it should be used for both genders.

A practical approach to difficult urinary catheterizations

Routine placement of transurethral catheters can be challenging in some situations, such as urethral strictures, severe phimosis and false passages. Intravaginal retraction of the urethral meatus can complicate Foley placement in postmenopausal females. In men, blind urethral procedures with mechanical or metal sounds without visual guidance or guidewire assistance are now discouraged due to the increased risk of urethral trauma and false passages. Newer techniques of urethral catheterization including guidewires, directed hydrophilic mechanical dilators, urethral balloon dilation, and direct vision endoscopic catheter systems are discussed, along with the new standardized protocol for difficult transurethral catheter insertions. Suprapubic catheter placement techniques, including percutaneous trocars and the use of the curved Lowsley tractor for initial suprapubic catheter insertion, are reviewed. Prevention and management of common catheter-related problems such as encrustation, leakage, Foley malposition, balloon cuffing and frequent blockages are discussed.

Liquid paraffin is superior to 2% lidocaine gel in reducing urethral pain during urodynamic study in men: A pilot study

AIMS

To compare the pain perception between intraurethral instillation of 2% lidocaine gel and liquid paraffin during Urodynamic study in men.

METHODS

A randomized, single-blind comparison trial was conducted. Forty men scheduled to undergo multichannel Urodynamic study were randomized to receive either 10 ml of 2% lidocaine gel (group 1, n = 20) or 10 ml of liquid paraffin (group 2, n = 20). Patients recorded their pain on a 0-10 visual analog scale prior to lubricant instillation, immediately after lubricant instillation, after the introduction of the Urodynamic catheter, 5 and 30 min after the catheter was taken out.

RESULTS

pain scores were significantly higher in group 1 compared to group 2 immediately after the instillation of the lubricants (4.2 ± 1.5 vs. 2.6 ± 0.9, P < 0.001) and after catheterization (4.8 ± 1.5 vs. 3.5 ± 1.1, P < 0.01). There were no differences in the pain scores between the two groups in the other time points that were evaluated.

CONCLUSIONS

Liquid paraffin is more efficient than 2% lidocaine gel in reducing urethral pain during Urodynamic study in men. Pain scores were specifically better during the instillation of the lubricant and during the delivery of the urethral catheter.

Optimal effect-site concentration of remifentanil when combined with dexmedetomidine in patients undergoing cystoscopy

Background

Cystoscopic procedure is a very common practice in the field of urology due to its ability to survey the bladder for a variety of indications. However, patients who undergo cystoscopy feel intense pain and discomfort. This study investigated the half maximal effective concentration (EC₅₀) of remifentanil in preventing cystoscope insertion pain under sedation using dexmedetomidine.

Methods

The study was prospectively conducted on 18 male patients, aged 18 to 65. Remifentail infusion was initiated together with dexmedetomidine, and started at a dose of 2.4 ng/ml on the first patient. The effect-site concentration (C_e) of remifentanil for each subsequent patient was determined by the previous patient's response using Dixon's up-and-down method with an interval of 0.3 ng/ml. Patients received a loading dose of 1.0 µg/kg dexmedetomidine over 10 minutes, followed by a maintenance dose of 0.6 µg/kg/hr. After the patient's OAA/S score (Observer's Assessment of Alertness/Sedation scale) reached 3-4, and the C_e of remifentanil reached target concentration, the urologist was allowed to insert the cystoscope and the pain responses were observed.

Results

The effect-site concentration of remifentanil required to prevent cystoscope insertion pain in 50% of patients under sedation using dexmedetomidine was 1.30 ± 0.12 ng/ml by Dixon's up-and-down method. The logistic regression curve of the probability of response showed that the EC₅₀ and EC₉₅ values (95% confidence limits) of remifentanil were 1.33 ng/ml (1.12-1.52 ng/ml) and 1.58 ng/ml (1.44-2.48 ng/ml), respectively.

Conclusions

Cystoscopic procedure can be carried out successfully without any pain or adverse effects by optimal remifentanil effect-site concentration (EC₅₀, 1.33 ng/ml; EC₉₅, 1.58 ng/ ml) combined with sedation using dexmedetomidine.

Cystoscopy in Non-Muscle-Invasive Bladder Cancer: When and how (Rigid or Flexible)

Cystoscopy is a common procedure in the urological practice due to its ability to survey the bladder for a variety of indications. It is the principal means of diagnosis and surveillance of bladder tumors. Hematuria is the most common finding of non-muscle-invasive bladder cancer (NMIBC), as a consequence of that it is one of the most frequent reasons to perform cystoscopy.

The follow-up of patients treated for NMIBC is of great importance because of the high incidence of recurrence and progression of the disease, whereby patients with NMIBC undergo cystoscopy repeatedly (every three months generally). At present, the schedule and methods of follow-up is a sign of patient's progression and recurrence risk, which has to be rated for each patient when follow-up begins.

Moreover, before the development of flexible cystoscopy, patients underwent rigid cystoscopy with greater discomfort. The advance of flexible cystoscopy has significantly decreased the pain and discomfort associated with the procedure, and the flexible instrument is currently considered the standard tool to perform cystoscopy. However, controversies exist about the use of anesthetic gel during cystoscopy.

The aim of this study is to report some short evidence about cystoscopy in particularly about the follow-up timing for NMIBC and the use of rigid or flexible cystoscopy.

OptiLube Active. The role of lubricants in urinary catheterisation

Catheterisation is necessary for many patients but places them at risk of developing uncomfortable and potentially lethal infections. Catheter insertion can also be painful. It is essential that all staff who perform the procedure have a clear understanding of the measures they should implement to reduce discomfort, trauma and the risk of infection to the patient. The need for staff to be trained and competent and to use an aseptic technique when undertaking the procedure are core principles for practice. Guidance advises that lubricating gels are used in all patients undergoing urethral catheterisation to minimise the risk of urethral trauma and associated infection. Gels containing a local anaesthetic make the procedure less uncomfortable, but must be applied correctly to be effective. This article will consider the actions of these gels and the potential benefits and risks associated with each, focusing on use of OptiLube Active with case studies.

ABC of flexible cystoscopy for junior trainee and general practitioner

Introduction:

Flexible cystoscopy is a diagnostic procedure usually performed under local anesthesia and has been used in the outpatient setting since the 1980s.

Methods:

We performed an electronic search of MEDLINE^® and the Cochrane Central Search Library between 1990 and 2010. Duplicate references were removed. One reviewer extracted the publications relevant to general clinical practice.

Results:

MEDLINE search using the MeSH (Medical Subject Headings) words “flexible” and “cystoscopy” revealed 274 titles, and there were 42 titles in the Cochrane Central Search Library. However, interestingly, only 13 published papers addressing the clinical practice of flexible cystoscopy in the English literature were identified.

Conclusions:

Flexible cystoscopy is a real revolution in the field of diagnostic urology.

Seeing is believing: a randomized controlled study from China of real-time visualization of flexible cystoscopy to improve male patient comfort

PURPOSE

To assess the impact on visual analog scale (VAS) pain scores of allowing male patients to view the procedure of flexible cystoscopy.

PATIENTS AND METHODS

A total of 86 male patients admitted to our hospital for flexile cystoscopy by a single urologist between 2010 and 2011 were randomized to two equal groups. Group 1 included 43 patients who were allowed to watch the video screen with the urologist. Group 2 included 43 patients who were unable to view the video monitor. All patients received the same real-time explanation during the cystoscopy. Patients recorded their pain feeling on a VAS ranging from 0 to 10 after the physician completed the cystoscopy. The pulse and respiratory rate were also recorded 5 minutes before the procedure and immediately after the procedure.

RESULTS

There was no statistically significant difference in the postprocedure pulse rate and respiratory rate between groups. The mean pain score on the VAS in group 1 was statistically significantly lower than that in group 2 (1.12±0.96 vs 3.33±2.50, P<0.001, Mann-Whitney U test). Patients who were allowed to watch the video screen experienced less discomfort at cystoscopy.

CONCLUSION

Real-time visualization of flexible cystoscopy with simultaneous explanation improves male patients' comfort.

Bladder catheterization in Greek nursing education: An audit of the skills taught

INTRODUCTION

The auditing of nurse teaching is in its infancy in Greece. One area urgently in need of audit is the teaching of male catheterization.

AIMS

To assess the current educational model regarding male bladder catheterization at a sole tertiary education nursing establishment in a major Greek city and to improve nurse undergraduate training by implementing appropriate recommendations for change to the current educational module and support these changes in the long term.

METHODS

A systematic search of international databases for guidelines or best practice regarding bladder catheterization was conducted. Audit measures included direct observation of the teaching process and compilation of a checklist.

RESULTS

The shortcomings are discussed under the following headings: patient pre-preparation, choice and quality of materials used, appropriate aseptic techniques, catheter withdrawal, connecting and handling the drainage bag, diminishing risk of Catheter Associated Urinary Track Infections (CAUTIs), no problem solving trouble-shooting training, textbook and educational resources, lack of national guidelines, setting of the educational experience.

CONCLUSIONS

The main problem with the teaching process exposed by the audit is entrenched use of an outmoded textbook with little effort to enrich teaching with current evidence base practices.

Impact of patient's self-viewing of flexible cystoscopy on pain using a visual analog scale in a randomized controlled trial

OBJECTIVES

To investigate the difference in pain score of patients allowed to view their flexible cystoscopy procedure compared with those who have not viewed the procedure on the video monitor.

METHODS

It is a prospective, randomized, controlled study. A total of 76 patients with different clinical indications for flexible cystoscopy were enrolled in the study. Patients were divided into 2 groups; group A and group B with 38 patients each. Group A patients viewed the procedure on a video monitor, whereas group B, the control group, did not. Statistical analyses were performed using a χ(2) test, Student's t test, and paired t test. A P value of <0.05 was considered to be statistically significant.

RESULTS

There were no statistically significant differences in demographic characteristics between the 2 groups. Mean age, duration of the procedure, and indications for the procedure were also comparable in the 2 groups. There was, however, a statistically significant difference in pain scores between the 2 groups (P < .001). The numbers of patients reporting pain in the study group (group A) were lower than in the control group (group B). There was a statistically significant difference in the postprocedural pulse rate; however, the systolic blood pressure pre- and postprocedure remained the same.

CONCLUSIONS

Patients' who viewed the cystoscopic procedure on a video monitor reported less pain on a visual analog scale compared with the control group.

(Almost) painless surgery: a historical review of the evolution of intraurethral anesthesia in urology

OBJECTIVE

The discovery of local anesthesia revolutionized urologic surgery. We investigate the evolution of intraurethral anesthesia in urologic surgery beginning in 1884.

METHODS

A review of the literature was performed, reviewing the history of local anesthesia for urologic surgery, with a specific emphasis on intraurethral anesthesia. Using the University of Rochester libraries catalog "Voyager," a search was performed reviewing the primary literature published on intraurethral anesthesia beginning from 1884 through 2009. We also reviewed published literature in Ovid Med and PubMed for articles relevant to the topic of intraurethral anesthesia. The search terms were intraurethral, cocaine, lidocaine, and anesthesia.

RESULTS

In the 1840s, it was demonstrated that ether, nitrous oxide, and chloroform could prevent the pain of surgery, resulting in a dramatic increase in surgery. At Massachusetts General Hospital between 1845 and 1847, surgeries increased 2.5-fold. Four decades later, it was demonstrated that cocaine allowed for adequate analgesia without the side effects of general anesthesia, resulting in a dramatic increase in urologic surgery. Cocaine was gradually replaced as an intraurethral anesthetic as safer local anesthetics, such as lidocaine, became introduced. Modern studies show conflicting results over the efficacy and ideal administration of intraurethral anesthetics.

CONCLUSIONS

Local anesthesia was rapidly accepted by urologists around the world and used in a wide variety of urologic surgeries, contributing to the acceptance of anesthesia and a revolution of the practice of surgery. To this day, intraurethral anesthesia continues to be a widely used and effective technique in urology, although the ideal method of use is largely left up to individual preference.

Flexible cystoscopy: a revolution in urological practice

Flexible cystoscopy has revolutionized the field of diagnostic urology. It can be done under local anaesthesia in the outpatient setting and is thus a highly useful tool. Its role in therapeutic urology is more limited but it still has a place in the management of certain conditions.

Difficult male urethral catheterization: a review of different approaches

PURPOSE

To review and compare the different methods for difficult male urethral catheterization described in selected literature.

MATERIALS AND METHODS

A PubMed search was done with the terms "difficult", "failed", or "complications" and "urethral catheterization", "transurethral catheterization", "Foley catheter", "urethral catheter" or "filiforms and followers". All articles addressing the issue of difficult adult male urethral catheterization were included.

RESULTS

Six main approaches were identified on the 14 articles included for review: 1) Passage of either a Glidewire, guide wire or filiform under direct vision; 2) Blind passage of a filiform, guide wire, Glidewire or hydrophilic catheter; 3) "The Peel-away sheath placed on a cystoscope/resectoscope technique"; 4) "The rigid ureteroscope placed inside the 22F Foley technique"; 5) Suprapubic catheterization; and 6) "The instillation of 60 cc of saline through the catheter as it is advanced technique".

CONCLUSION

There is a paucity of prospective data comparing the benefits, risks, success rates and complications of the different approaches for difficult Foley catheter placement. Our suggested approach starts with the initial attempt at urethral catheterization with an 18F coude and a 12F silicone catheter. If these fail, using a flexible cystoscope or the blind Glidewire technique are reasonable alternatives. If dilatation of a stricture is necessary, ureteric dilatators or a urethral balloon dilatator are recommended.