Cystoscopy - Nursing Responsibilities

Cystoscopy, also called cystoureterography or prostatography, is an invasive procedure that directly visualizes the urethra, bladder, and ureteral orifices through transurethral insertion of a cystoscope. It is one of the most common procedures a urologic surgeon performs, done either as a short office procedure or in the operating room under general anesthesia (StatPearls). A urinalysis and urine culture are commonly obtained beforehand to rule out active infection (Urology Care Foundation).

There are two types. Rigid cystoscopy uses a thin lighted tube with an obturator and a telescope (lens and light system). It is used to take tissue samples and carry out complicated surgery, done under general or spinal anesthesia. Flexible cystoscopy uses a flexible fiberoptic telescope to diagnose urinary abnormalities and evaluate treatment, done under local anesthesia.

Indication

Cystoscopy is performed for diagnostic and therapeutic purposes.

Diagnostic Cystoscopy

• Assess kidney function by collecting a urine specimen through ureteral catheters
• Assess changes in urinary elimination patterns
• Differentiate benign from malignant bladder lesions
• Identify the source of hematuria
• Investigate recurrent urinary tract infection
• Evaluate the extent of an enlarged prostate and degree of obstruction
• Evaluate urinary tract abnormalities such as dysuria, urgency, incontinence, frequency, retention, and inadequate stream
• Diagnose congenital anomalies such as ureteroceles, diverticula, duplicate ureters, urethral or ureteral strictures, and areas of inflammation or ulceration

Therapeutic Cystoscopy

• Coagulate bleeding areas
• Dilate the urethra and ureters
• Remove and resect polyps and small bladder tumors
• Remove foreign bodies and renal calculi
• Implant radioactive seeds into a tumor
• Place ureteral catheters to drain urine from the renal pelvis or for retrograde pyelography
• Resect a hypertrophied or malignant prostate gland (transurethral resection of the prostate)

Contraindication

• Acute urethritis, prostatitis, or cystitis, since instrumentation raises the risk of bacterial invasion and sepsis
• Bleeding disorders, since instrumentation may cause further bleeding from the lower urinary tract
• Pregnancy, unless the potential benefit outweighs the risk of maternal and fetal damage

Interfering Factors

• Inability to cooperate or stay still due to age, significant pain, or mental status
• Failure to follow dietary restrictions, which may force cancellation or repetition

Procedure

Cystoscopy is usually done in the operating room but can be done in a clinic.

1. Empty the bladder. The patient voids before the procedure and changes into a surgical gown.
2. Position in lithotomy. The buttocks sit at the edge of the table with feet in stirrups.
3. Prep the skin. Clean the genitalia with antiseptic solution and drape the patient.
4. Give sedative or local anesthesia. A local anesthetic is instilled into the urethra if general anesthesia is not used.
5. Insert the cystoscope. A cystoscope or urethroscope examines the urethra first. The urethroscope has a sheath that can stay in place so the cystoscope passes through it, avoiding repeated instrumentation.
6. Examine the urine. After insertion, a sample of residual urine may be taken for culture or analysis.
7. Fill the bladder with irrigating solution. Irrigation fluid through the scope aids visualization.
8. Perform added procedures as needed.

• A prostatic tumor may be biopsied with a cytology brush or forceps through the scope. A small, localized tumor can be excised and fulgurated (transurethral resection of the bladder).
• Polyps can be identified and excised.
• Ulcers or bleeding sites can be fulgurated with electrocautery.
• Renal calculi can be crushed and removed from the ureters and bladder.
• Ureteral catheters can be inserted to obtain urine from each kidney for comparison and radiographic study.
• Ureteral and urethral strictures can be dilated.

9. Remove the cystoscope. Withdraw it once the exam and related procedures are complete.
10. Send specimens to the lab. Place specimens in proper containers, label them, and transport immediately.

Nursing Responsibilities

Before cystoscopy

• Assess understanding and answer questions. The procedure is usually done in a urology clinic and takes about 30-45 minutes. Tell the patient who performs it, where, and who else is involved.
• Obtain informed consent. Signed before any medications are given.
• Withhold blood thinners. Examples: aspirin, warfarin (Coumadin), enoxaparin (Lovenox), heparin, clopidogrel (Plavix), dabigatran (Pradaxa).
• Give fasting or non-fasting instructions. Without general anesthesia, no food or fluid restriction is needed. With general anesthesia, the patient fasts at least 6 to 8 hours before the test.
• Establish an IV line. For fluids, anesthetics, sedatives, or emergency medications.
• Prepare the patient. Empty the bladder and change into the gown.
• Administer medications as ordered. Preoperative medications are given 1 hour before the test. The sedative decreases bladder sphincter spasm and reduces discomfort.

After cystoscopy

• Monitor vital signs. Rising pulse (tachycardia) and falling blood pressure (hypotension) may signal hemorrhage.
• Assess ability to void within 24 hours. Urinary retention may follow edema from instrumentation.
• Observe urine color. Pink-tinged urine and mild burning for a few voidings is normal and usually resolves within 2 to 3 days.
• Encourage fluids. Fluids flush the bladder, reduce bleeding, and lower infection risk.
• Encourage deep breathing. This can relieve bladder spasms.
• Provide warm sitz baths and mild analgesics as ordered. These ease urinary discomfort and relax muscle.
• Report serious complications (sepsis, bladder perforation, hematuria). Persistent severe flank pain, temperature over 101°F, chills, bright red blood or clots in the urine, painful urination, or urinary retention go to the provider immediately.

Normal Results

• Normal size, shape, and position of the urethra, bladder, and urethral structure

Abnormal Results

• Bladder cancer
• Diverticulum of the bladder, fistula, stones, and strictures
• Foreign body
• Infection or inflammation
• Obstruction
• Polyps
• Prostatic hyperplasia
• Prostatitis
• Renal calculi
• Tumors
• Ureteral calculi
• Ureteral reflux
• Ureteral or urethral strictures
• Ureterocele
• Urinary fistula
• Urinary tract malformation and congenital anomalies

Frequently Asked Questions

What symptoms are normal after a cystoscopy, and what is not?

Pink-tinged urine and mild burning on urination for a few voidings are expected and usually clear within 2 to 3 days. Bright red blood or clots, fever over 101°F with chills, severe flank pain, or the inability to void are not normal and should be reported to the provider right away.

Does a cystoscopy hurt?

Flexible cystoscopy is typically done under local anesthesia and causes brief discomfort or a stinging sensation rather than true pain. Rigid cystoscopy, which is used for biopsy and surgical work, is done under general or spinal anesthesia so the patient feels nothing during the procedure.

Why is a urine culture done before a cystoscopy?

Active urethritis, prostatitis, or cystitis is a contraindication because passing the scope through an infected tract can push bacteria into the bloodstream and cause sepsis. A urinalysis and urine culture beforehand confirm the urinary tract is clear of active infection (StatPearls).

Should anticoagulants be stopped before a cystoscopy?

Blood thinners such as aspirin, warfarin, enoxaparin, heparin, clopidogrel, and dabigatran are usually withheld before the procedure because instrumentation of the lower urinary tract can cause bleeding. The exact hold time is set by the provider based on the drug and the patient's clotting risk.

How long does a cystoscopy take?

A diagnostic cystoscopy in a urology clinic usually takes about 30 to 45 minutes, though the patient may wait longer for preparation, sedation recovery, and any added procedures such as biopsy or stone removal.

Why encourage fluids and deep breathing afterward?

Increasing fluids flushes the bladder, dilutes the urine, reduces bleeding, and lowers infection risk after instrumentation. Deep breathing helps relieve bladder spasms, and warm sitz baths with mild analgesics ease post-procedure discomfort.