Intraurethral Lubricants: A Critical Literature Review and Recommendations

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.

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.

Lidocaine Gel for Urethral Catheterization in Children: A Meta-Analysis

OBJECTIVE

To compare the efficacy and safety of lidocaine gel vs nonanesthetic gel (NAG) in reducing transurethral bladder catheterization (TUBC) procedural pain in children.

STUDY DESIGN

A systematic literature search was done using electronic medical databases and trial registries up to September 2016 with no language restrictions. Randomized controlled trials (RCTs) that assessed the efficacy and safety of lidocaine gel vs NAG in reducing TUBC-associated pain in children were screened, identified, and appraised. Risks of bias and study quality of the eligible trials were assessed according to the Cochrane Collaboration recommendations. Various pain assessment scales from the included studies were extracted as mean differences and standard deviations for each treatment group. Standardized mean differences (SMDs) were generated with 95% CIs for between-group difference estimation. Effect estimates were pooled using the inverse variance method with a random-effects model. Subgroup analysis was performed for different age groups.

RESULTS

Five RCTs (with a total of 369 children) were included. Overall pooled effect estimates showed that compared with NAG, lidocaine gel has no significant benefit in decreasing TUBC-associated pain in children (SMD, -0.22; 95% CI, -0.65 to 0.21). Effect estimates from 4 studies revealed no difference in pain reduction between the lidocaine gel and NAG in children aged <4 years (SMD, 0.01; 95% CI, -0.22 to 0.24). No serious adverse events from the lidocaine gel use were reported in any of the studies.

CONCLUSIONS

Lidocaine gel does not appear to reduce TUBC pain compared with NAG, specifically in children aged <4 years.

PROSPERO REGISTRATION NUMBER

CRD42016050018.

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.

[Local analgesia during flexible cystoscopy in male patients: A non-inferiority study comparing Xylocaine® gel to Instillagel® Lido]

INTRODUCTION

Local anesthesia using urethral gel has been proven to reduce discomfort of male patients during flexible cystoscopy. This study was a non-inferiority study between two lidocain-containing urethral gel (Instillagel^® Lido and Xylocaine^® gel).

METHODS

A prospective single center study was conducted between June 2014 and November 2014. Male patients seen in the office and in whom a flexible cystoscopy was planned were included in the present study and received urethral instillation of either Xylocaine^® gel or Instillagel^® Lido at least 5minutes before flexible cystoscopy. No other anesthetic agent was used. Primary endpoint was pain during the procedure, assessed through visual analog scale (VAS) from 0 to 10.

RESULTS

Four hundred and sixty-one men were included: 233 in the Instillagel^® Lido group and 228 in the Xylocaine^® gel group. Indications of flexible cystoscopy non-muscle invasive bladder cancer follow-up in 44 % of cases, hematuria work-up in 21 % of cases and lower urinary tract symptoms work-up in 35 %. Patients' age was comparable betwwen both groups: 64.5 years (±1.1) in the Instillagel^® Lido group and 66.2 years (±1.1) in the Xylocaine^® gel group (P=0.29). The mean VAS was 0.8 (±0.1) in the Instillagel^® Lido group and 0.6 (±0.1) in the Xylocaine^® gel group (P=0.10). The non-inferiority criterion was reached (P<0.001) as the average difference in VAS between the two groups was 0.2 with a confidence interval not comprising 1 (CI 97.5 %: -0.47; 0.07).

CONCLUSION

In this prospective study, Instillagel^® Lido was not inferior to Xylocaine^® gel for local analgesia during flexible cystoscopy in male patients.

LEVEL OF EVIDENCE

4.

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.

Varna tehnika dolgotrajne intermitentne samokatetrizacije

Uvod: Intermitentna samokatetrizacija je prednostna metoda praznjenja sečnega mehurja pri pacientih z zastojem urina. Medicinska sestra običajno pacienta nauči čiste ali aseptične tehnike samokatetrizacije. Namen prispevka je s pregledom literature ugotoviti, ali obstaja optimalna tehnika intermitentne samokatetrizacije, ki bi jo medicinske sestre priporočale pacientom. Metode: Uporabljen je bil sistematični pregled literature v bazah podatkov: CINAHL, Medline, ProQuest, COBIB.SI in Cochrane Library. Vključena je bila literatura od prve omembe samokatetrizacije leta 1972 do leta 2016. S selekcijo prvotnih 350 virov smo glede na njihovo skladnost z namenom raziskave izbrali 67 enot literature. Rezultati: Osemnajst referenc, izbranih z orodjem CASP, je bilo objavljenih med letoma 1992 in 2015: šest randomiziranih kliničnih in pet kohortnih raziskav ter šest sistematičnih pregledov literature in ena kritika. Ključne spremenljivke analize zbranih podatkov so bile sterilnost katetra, vrsta vlažilnega gela in higiena periuretralnega področja. Diskusija in zaključek: Nobena tehnika intermitentne samokatetrizacije se ne izkaže kot optimalna. Ob upoštevanju značilnosti in sposobnosti pacienta je za slovenske razmere najboljša uporaba sterilnega materiala za enkratno uporabo (katetra in vlažilnega gela), higiena periuretralnega področja s sterilno solucijo in tamponi ter tehnika nedotikanja.

Catheter lubrication and fixation: interventions

This article looks at the indications for catheterisation, the anatomy of the urethra, the importance of asepsis and the rationale for the use of urethral lubrication for catheter insertion. The variations of lubrication available are discussed, including the use of products containing lidocaine and chlorhexidine. It then considers the problems caused by traction to the catheter and discusses the securement devices available for preventing tissue damage at the bladder neck, within the urethra and also at the meatus. The variation of devices is examined along with the potential problems associated with their use. Finally, it discusses the importance of clinicians being knowledgeable about the problems looked at and how to resolve them.

Near fatal intra-operative anaphylaxis to chlorhexidine--is it time to change practice?

The authors report a case of a near fatal anaphylactic reaction to chlorhexidine. Increasingly adverse reactions are being reported with the use of chlorhexidine. Serious reactions are related to use on mucous membranes and acceptable alternatives are readily available. Therefore, the fundamental question that must be asked is: is it time to withdraw chlorhexidine preparations used for mucous membranes?