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Effect of the Rate of Delivery of Lignocaine Gel on Patient Discomfort Perception prior to Performing Flexible Cystoscopy
Abstract
Flexible cystoscopy is commonly performed under local anaesthesia. Instillation of lignocaine gel is commonly associated with urethral discomfort, which in some cases results in fierce opposition to further flexible cystoscopy under local anaesthesia. Although studies have demonstrated that the temperature of lignocaine can influence the level of discomfort experienced, to date no study has investigated the influence of the rate of lignocaine delivery on perceived discomfort. We therefore performed a prospective, randomised study to investigate this in patients undergoing flexible cystoscopy. One hundred consenting men were randomised to receive 11 ml of 2% lignocaine hydrochloride gel over either 2 or 10 s. The groups were well matched for age. After instillation of the gel, the patients were immediately asked to score their discomfort using a visual analogue scale. The discomfort experienced by patients that received the gel over 10 s was significantly (p < 0.05; Student's t test) less than those that received it over 2 s. This was irrelevant of the age of the patient and the number of previous cystoscopies performed. We have demonstrated that slow administration results in decreased discomfort. This may, in turn, reduce the need to resort to general anaesthesia, which is associated with increased morbidity and cost.
... However, in both studies the authors admitted a lack of statistical power because there were too few subjects in each subgroup. Moreover, the delivery time of lignocaine gel is a critical issue for pain perception during flexible cystoscopy [7]. Injection with lignocaine gel over a period of 10 s causes significantly less urethral discomfort than delivering it over 2 s. ...
... Three studies focused on the discomfort during the delivery of lignocaine gel before instrumentation [3,4,7]. In two studies with rapid injection (delivery times 2 and 3 s), lignocaine gel caused more discomfort than aqueous gel [3,4], with one study showing less pain with a delivery time of 10 s rather than 2 s [7]. ...
... Three studies focused on the discomfort during the delivery of lignocaine gel before instrumentation [3,4,7]. In two studies with rapid injection (delivery times 2 and 3 s), lignocaine gel caused more discomfort than aqueous gel [3,4], with one study showing less pain with a delivery time of 10 s rather than 2 s [7]. ...
... To the best of our knowledge there is no study that evaluated the impact of instillation of local anesthetic gel on the diagnostic accuracy of RGU. The room temperature at which the anesthetic gel is given and the rate of instillation were reported to affect the degree of discomfort caused by the local anesthetic gel678. In the study of Thompson et al. [6] and Goel et al. [7], it has been found that instillation of cooled local anesthetic gel at 4°C, produced more discomfort than at 22°C. ...
... In the study of Thompson et al. [6] and Goel et al. [7], it has been found that instillation of cooled local anesthetic gel at 4°C, produced more discomfort than at 22°C. In addition , Khan and associates [8] found that the slow delivery rate (11 ml of gel over 10 s) was associated with less urethral discomfort than the rapid instillation (11 ml gel over 2 s) [5]. Therefore, we elected to use the slow delivery rate (10 ml over 10 s) at room temperature (22°C). ...
To investigate the implication of topical urethral anesthetic gel on the evaluation of retrograde urethrography (RGU) MATERIAL AND METHODS: In this prospective study, 20 patients with a mean age of 46 years were enrolled. All these patients were subjected to RGU because of suspecting a urethral stricture. Of these 13 had a history of open or endoscopic urethral manipulation, while seven had no such history. In all patients 10 ml of Gelicain gel 2% (lidocainhydrocloride) was used as local anesthetic gel at temperature of 22 degrees C. The injection was made gradually over 10 s. The first set of RGU was done without local anesthesia and the second image was taken after 10 min of instillation of 2% gelicain gel. All images were evaluated by the same radiologist. The diameter of the urethra was measured by capture screen during fluoroscopy immediately distal to the stricture site in case of urethral strictures and at the middle of the bulbous urethra in other cases.
In all patients, the mean diameter of the urethra at the selected site was 8.7 +/- 2.5 mm before and 9.4 +/- 2.9 mm after instillation of local anesthetic gel (P = 0.005). The stricture was diagnosed in 13 cases while seven patients had no stricture. The clinical diagnosis of a possible stricture was the same before and after instillation of the local agent in all patients.
Instillation of the local anesthetic gel before RGU produces a slight but statistically significant increase in the diameter of the urethra at the selected sites. However, neither the radiologic reading of RGU nor the clinical diagnosis of a possible stricture was changed because of this increment.
... Moreover, Ho et al. suggested that the intraurethral injection of lidocaine gel can actually be more painful than the injection of plain gel, due to the chemical composition of lidocaine-based lubricant [32]. Regardless, it has been proven that in order to maximize the patient's comfort during the administration of the gel, it should be cold (ideally 4 degrees Celsius) and instilled slowly (over 10 seconds) [33][34][35] (Table 2). ...
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.
... Khan et al. [21] reported that delivering intraurethral lidocaine gel during 10 seconds resulted in less pain than a delivery rate of 2 seconds. We slowly delivered intraurethral lidocaine and plain lubricating gel in all patients. ...
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.
... These include use of intraurethral anesthetic agents, general anesthesia, pre-treatment with intramuscular narcotics, non-pharmacological replacement therapies, use of different lidocaine volumes, squeezing the irrigation liquid bag, simultaneous monitor visualization, nitrous oxide inhalation, slow delivery of local anesthetics, use of a specialized flexible cystoscope sheath, and transcutaneous electrical nerve stimulation, to name a few. [1][2][3][4][5][6][7][8][9][10] Despite all these options, office-based cystoscopy is still associated with patient discomfort and the use of intraurethral lidocaine has been universally accepted as the most effective means to ameliorate procedure-related pain. 11 It is well-documented that cooling of tissue leads to augmented effects of local anesthesia. ...
Introduction:
Office-based flexible cystoscopy is often associated with considerable discomfort in male patients. We devised this study to prospectively evaluate the efficacy of cooling intraurethral lidocaine jelly to 4ºC prior to use in office-based cystoscopy in an effort to reduce male patient discomfort.
Methods:
A total of 600 male patients scheduled for office diagnostic cystoscopy were enrolled and randomized into three groups for a prospectively controlled, double-blind study. Each group received one of the three methods of intraurethral lubrication: plain room temperature lubricant (control) (CON), room temperature lidocaine (LI), or lidocaine at 4ºC (LI4ºC). Perceived pain was recorded on a Likert visual analog scale (VAS) of 1-10 where 0=no pain and 10=excruciating pain. Kruskal-Wallis test assessed the efficacy of cooling lidocaine compared to room temperature lidocaine and control. Subjective pain reporting was corroborated with instantaneous objective pulse rate recording eliminating perception bias.
Results:
There was no significant difference in cystoscopy duration between all groups. Mean pain scores (mean ± standard deviation) were 4.05±0.91, 2.74±1.01, and 1.8±0.84, respectively, for groups CON, LI, and LI4ºC (p=0.02). There was a 32.34% reduction in the mean pain score of LI and a further reduction of 34.3% was achieved in LI4ºC when compared to CON. Body mass index (BMI) and prostate weight had a significant positive correlation with pain score, whereas no such correlation was found with age.
Conclusions:
Cooling lidocaine to 4ºC provides additional analgesic benefit in men undergoing office cystoscopy and increases compliance.
... Flexible cystoscopy has greatly dereased patients' discomfort and made cystoscopy more tolerable, especially for male patients; however, pain is still inevitable during this procedure. So many studies had examined different methods to reduce male patients' discomfort, such as assessment of the volume of lidocaine, 10 increasing hydrostatic pressure by squeezing the irrigation solution bag, 11 cooled lignocaine gel, 12 simultaneous visualization, 13 application of nitrous oxide inhalation, 14 slow delivery of local anesthetics, 15 a special flexible cystoscope sheath, 16 and transcutaneous electrical nerve stimulation. 17 Controversy still exists, however. ...
Purpose:
To determine whether listening to music during cystoscopy decreases anxiety, pain, and dissatisfaction among patients and results in a more comfortable and better-tolerated procedure.
Materials and methods:
Seventy male patients who underwent rigid cystoscopy between May 2011 and December 2011 were randomized into the following: no music (Group I, n=35) or classical music during procedure (Group II, n=35). Before cystoscopy, lidocaine gel was instilled in the urethra, and both groups viewed their procedures on a video monitor. Anxiety levels were quantified according to the State-Trait Anxiety Inventory. A visual analog scale (0-10) was used for a self-assessment of satisfaction, discomfort, and willingness among patients to repeat the cystoscopy.
Results:
Demographic characteristics, mean age, procedure duration, and procedure indications were statistically similar between the two groups. The mean anxiety level and mean pain score of Group II were significantly lower than those of Group I (p<0.001 for both). Group II also carried a significant greater mean satisfaction score compared with Group I (p<0.001). Statistically significant differences were detected between groups in the postprocedural pulse rate and the systolic blood pressure (p=0.012 and p=0.008, respectively), whereas preprocedure pulse rate and systolic blood pressure were similar.
Conclusions:
Listening to music during rigid cystoscopy significantly reduces feelings of pain, discomfort, and dissatisfaction. Music can serve as a simple, inexpensive, and effective adjunct to sedation during cystoscopy. We recommend the application of music during rigid cystoscopy for clinical use.
... Choong and associates demonstrated that anesthesia with 20mL of 2% lignocaine gel is more effective when left on for a longer period of time than current practices (Choong et al., 1997). It has been demonstrated that if lignocaine is applied slowly to administer local anesthesia, the patient discomfort lessens (Khan et al., 2002). In a comparison of 2% lignocaine gel with plain lubricating gel during cystoscopy, there was no analgesic difference noted between the two (Birch et al., 1994). ...
... 7,8 También se ha sugerido que promover mejorías en la disminución del dolor no es posible debido a la incomodidad en general de la endoscopia flexible; sin embargo, existen detalles como poner el gel con lidocaína intrauretral durante 10 segundos el cual resulta ser menos doloroso que colocarlo rápidamente en dos segundos. 9 Aun así es una experiencia sensorial y emocional desagradable, asociada con un daño tisular, real o potencial. 10 Por tanto, un objetivo primordial es utilizar técnicas eficaces para disminuir el dolor. ...
Introducción: la cistoscopia es uno de los procedimientos más comunes, se cree que la visualización del procedimiento reduce
el dolor, por lo tanto, nuestro objetivo fue determinar si la visualización del procedimiento endourológico en consultorio reduce
el nivel del dolor. Material y métodos: se presenta un estudio comparativo, prospectivo, transversal y aleatorio. Participaron 40
pacientes, se les realizó un procedimiento endourológico en consultorio, utilizamos cistoscopio flexible y video monitor para todos
los casos, la percepción del dolor se valoró con la escala del termómetro de Iowa. Resultados: obtuvimos una media de edad
de 54.08 años, el 61.5 % mujeres. La indicación más frecuente fue el retiro de catéter JJ por litiasis urinaria (64.1 %), seguido
de cistoscopia por Ca vesical (23.1 %). Discusión: se analizaron las comorbilidades como factores de riesgo para dolor, sin ser
significativo (χ2 con p > 0.05 y OR no significativa en todos los casos). La duración del procedimiento mostró tendencia a ser mayor
en los pacientes que visualizaron el procedimiento. No encontramos diferencia significativa en la percepción del dolor de los
pacientes que ven su procedimiento (U de Mann-Whitney p = 0.368), pero obtuvimos una correlación negativa entre la talla de los
pacientes y la percepción del dolor, con una p significativa (Rho; -.325 con p = 0.043). Conclusiones: no encontramos beneficio
en los pacientes que ven su procedimiento, debido a que no disminuye la percepción del dolor por lo que no recomendamos esta
práctica.
... Although discomfort was lesser in both the instances with cooled lignocaine, initial discomfort was significantly lesser. Khan et al 26 explained that in tubular organs such as the ureter, vagina, gut, salivary and bile ducts, and sacular organs such as the urinary bladder, the pain/discomfort caused by distension works through a purinergic mechanosensory transduction mechanism so reduction of shear stress can be done by slow administration of lignocaine. We have also demonstrated that discomfort is lower when lignocaine was administered over 10 seconds compared to over 2 seconds with significant reduction in initial discomfort. ...
Introduction: Intraurethral instillation of 2% lignocaine hydrochloride is associated with discomfort and stinging sensation, especially to male patients. This study was aimed to determine whether slow instillation and cooled gel reduce this discomfort.
Materials and Methods: A prospective randomized study was done comparing initial and procedural discomfort between 2% lignocaine instilled at room temperature and cooled to 4° C, and that instilled over 2 seconds and 10 seconds. Hundred and sixty male patients were divided into two groups of eighty each for the two studies.
Results: Significant reduction in initial discomfort was observed with 10ml of 2% lignocaine hydrochloride cooled to 4° C and also when instilled over 10 seconds. Although procedural discomfort was also lesser in these two sets, it was not statistically significant.
Conclusions: Discomfort, the most common complaint of male patients during rigid cystoscopy, can be reduced by slow instillation of lignocaine hydrochloride gel and also if the gel is cooled to 4° C.
... Brekkan et al. and Holmes et al. independently suggested increasing the volume of lidocaine gel to 20 ml before cystoscopy in men, especially in patients younger than 55 years [14,15]. Khan et al. outlined the importance of the delivery rate of lidocaine gel, indicating that slow administration within 10 s reduces patient discomfort compared to 2-second administration [16]. Vasudeva et al. and Losco et al. independently examined the optimal dwell time of intraurethral lidocaine gel before insertion of the cystoscope. ...
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.
... Lignocaine gel has been shown to have minimal effect in many studies in flexible cystoscopy. [10,11] Ureteroscopic stent removal of mildly upmigrated DJ stents (below pelvic brim) was performed under 2% intraurethral lignocaine gel or no anesthesia. [12] They showed that ureteroscopy was similarly painful in males and females. ...
Introduction
Double J (DJ) stents are often removed under local anesthesia using a rigid cystoscope. Patients experience significant pain during this procedure and also continue to have discomfort during voiding for a few days. We assessed the efficacy and safety of preemptive oral diclofenac in pain relief in patients undergoing DJ stent removal (DJSR) by rigid cystoscopy compared to placebo.
Methods
Consecutive consenting male patients undergoing DJSR under local anesthesia between March 2014 and July 2015 were enrolled. Patients were randomized to receive 75 mg oral diclofenac (Group A) or placebo (Group B) 1 h before procedure by double-blind randomization. Intraurethral 2% lignocaine gel (25 ml) was used in both groups. Pain during rigid cystoscopy, pain at the first void, and at 24 h after cystoscopy was assessed using visual analog scale (VAS) (0–100). Adverse reactions to diclofenac and episodes of acute urinary retention, if any, were assessed (Trial registered at clinicaltrials.gov: NCT02598102).
Results
A total of 121 males (Group A [n = 62]; Group B [n = 59]) underwent stent removal. The median (Interquartile range) VAS during the procedure in Group A was 30 (30) and Group B was 60 (30) (P < 0.001), at first void was 30 (30) and 70 (30) (P < 0.001) and at 24 h postoperatively was 20 (20) and 40 (20) (P < 0.001). The incidence of epigastric pain, nausea, vomiting, and acute urinary retention was comparable in the two groups (P > 0.05).
Conclusions
A single oral dose of diclofenac administered 1 h before DJSR using rigid cystoscope under intraurethral lignocaine anesthesia decreases pain significantly during and up to 24 h postprocedure with minimal side effects.
Objective:
The study aimed to test the hypothesis that the instillation of lidocaine gel does not reduce the pain related to flexible cystoscopy.
Material and methods:
A prospective randomized study was designed to compare the pain perception between intraurethral instillation of lidocaine gel and saline solution in flexible cystoscopy. One hundred consecutive male patients attending for flexible cystoscopy were randomized to receive 10 ml of lidocaine gel or 10 ml of saline solution. Saline solution was also used for the irrigation pressure. Patients recorded their pain on a 10 cm Visual Analog Scale before and after the procedure. Patients also assessed whether the cystoscopy was more painful than the previous one. Statistical comparison was made using the t test for parametrical data and the Mann-Whitney U test for non-parametrical data.
Results:
Mean pain score in the lidocaine group was 0.67 ± 1.11 cm (range 0-5) compared to 0.55 ± 1.10 cm (range 0-5) in the saline solution group. Pain perception did not differ significantly between the 2 groups (mean difference 0.12 cm, 95% CI -0.32 to 0.55, p = 0.40).
Conclusions:
Prior lubrication of the urethra does not reduce the pain produced during flexible cystoscopy. The introduction of flexible cystoscopes under direct vision and with an irrigation pressure might guarantee sufficient comfort and the lubricant gel instillation could be avoided.
Topical urethral analgesia with 2% lignocaine gel for office procedures is an accepted practice in contemporary urology. However, instillation of 2% lignocaine gel into the urethra is associated with discomfort in some patients.
Forty consenting men reporting for cystoscopy under local anesthesia were randomized to receive 10 ml of 2% lignocaine hydrochloride gel at 4 degrees C and 22 degrees C. After instillation of the gel the patients were immediately asked to score the pain using a nongraphical visual analogue scale.
The pain scores were analyzed using the paired Student's t-test. There was significant reduction in pain scores in the group receiving gel at 4 degrees C compared with the group at 22 degrees C (P < 0.05).
Refrigerating the gel to 4 degrees C can significantly reduce the initial discomfort associated with instillation of 2% lignocaine hydrochloride into the male urethra.
To determine whether increased hydrostatic pressure by simple manual compression ("bag squeeze") of the irrigation solution bag (500 mL of 0.9% saline) during passage of the flexible cystoscope will reduce patient discomfort.
A total of 151 male patients undergoing diagnostic and review flexible cystoscopies were randomized to "squeeze" (n = 72) or "no squeeze" (n = 79) as the cystoscope was passed from below the external sphincter until after the bladder neck was negotiated. All patients had received 10 mL of 2% lidocaine gel beforehand. A 10-point visual analog pain scale assessing cystoscopy insertion was completed by the patients after the procedure.
The mean pain score was 1.38 (95% confidence interval 0.99-1.77) in the squeeze group and 3.00 (95% confidence interval 2.55-3.46) in the no-squeeze group (P < .001, Mann-Whitney U test). Patient age, procedure indication (diagnostic and review), and grade of clinician performing the cystoscopy had no effect on the findings.
The results of our study have shown that the squeeze technique during insertion of a flexible cystoscope significantly decreases the discomfort of the procedure. It is strongly recommended in all male patients.
Cystoscopy is one of the most common examinations in urologic outpatient clinics. Various anesthetic approaches have been used to make cystoscopy more tolerable for patients. The aim of the present prospective randomized study was to evaluate the efficacy of lidocaine hydrochloride gel compared to dimethyl sulfoxide (DMSO) with lidocaine in rigid cystoscopy.
Male patients requiring 17F rigid cystoscopy were eligible for inclusion in this study. A total of 140 patients were divided into two groups: group 1 (n=70) received approximately 11 mL of 2% lidocaine gel intraurethrally, while in group 2 (n=70) approximately 10 mL of 40% DMSO with an amount of lidocaine equal to that in the lidocaine gel was smeared around the scope and external urethral meatus. A penile clamp was placed for 15 minutes and 5 minutes in group 1 and group 2, respectively. Immediately after cystoscopic examination pain was scored on a 10-cm visual analog scale.
The mean pain scores after the procedure for group 1 and group 2 were 3.9+/-1.1 and 2.1+/-1.0, respectively. The pain scores were significantly lower for group 2 than for group 1 (P=0.015). No patients needed additional anesthetic agents or sedatives due to insufficient analgesia, and there were no serious side effects in either group.
Our study has shown that DMSO with lidocaine gel causes significantly less delivery discomfort in the male urethra than lidocaine hydrochloride gel. The advantages of DMSO with lidocaine are the mixture takes less time to act and had lower pain scores.
To evaluate the effectiveness of transperineal urethrosphincteric block (TUSB) in providing analgesia during visual internal urethrotomy for patients with anterior urethral strictures.
A total of 26 consecutive patients scheduled for elective visual internal urethrotomy for symptomatic urethral stricture were considered for this prospective study. Twenty-four patients agreed to participate in the study. Their demographics and medical conditions were recorded. Twenty-five percent of the patients had comorbid conditions that would have put them at high risk for general anesthesia. All patients had TUSB as the primary method of analgesia, using 1% lidocaine. Postoperatively, patients were asked to score the severity of the pain experienced during TUSB and during the transurethral surgery on a scale from 0 to 10. Postoperative adverse effects and the need for sedation or additional analgesia were recorded. All patients rated their overall satisfaction with the analgesia.
Patient mean age was 43.5 years (range 26-71 years). The mean pain score during instillation of the transperineal block was 1.9 (range 0-3), and for visual internal urethrotomy was 1 (range 0-5). No sedation, narcotics, or additional analgesia were required and no postoperative adverse effects were encountered. Ninety-two percent of the patients were very satisfied with the method of analgesia.
TUSB is a safe and effective method of local analgesia for visual internal urethrotomy in patients with anterior urethral strictures, and is particularly suitable for those at high risk of general anesthesia.
The current literature shows mixed results for the effectiveness of topical intraurethral lidocaine gel as local anesthesia during flexible cystoscopy. We performed a meta-analysis of randomized, controlled trials of the efficacy of 2% lidocaine vs plain gel for decreasing the pain that male patients incur during flexible cystoscopy.
A search of the literature from 1950 to September 2006 yielded 46 applicable articles. Search terms included cystoscopy and pain. Study selection included randomized controlled trials, flexible cystoscopy, males, control groups receiving plain gel and treatment groups receiving 2% lidocaine before cystoscopy. Data extraction was done by 2 of us (ARP and JSJ) who independently reviewed each study and were blinded to identifying features. The primary outcome measured was pain incurred by the patient throughout the entire cystoscopy procedure, as measured using a visual analog score.
Data from 9 eligible trials on a total of 817 patients in 7 publications were included in the meta-analysis. Using a random effects model the difference between visual analog scale pain scores in patients receiving 2% lidocaine and plain gel was estimated to be -4.61 (approximate 95% CI -9.6, 0.385), indicating no statistically significant difference.
Based on a meta-analysis of 9 randomized controlled trials there is no evidence to suggest a statistically significant difference in the efficacy of pain control between lidocaine gel and plain gel lubrication in men during flexible cystoscopy. This supports the conclusion that its benefit is limited to lubrication and any other perceived benefit is consistent with placebo.
Flexible cystoscopy in men younger than 55 years is painful despite the current best standard anesthesia (20 ml 2% lidocaine gel 15 minutes before endoscopy). The anesthetic value of lidocaine gel is debated and led us to seek an alternative. Nitrous oxide is a well established analgesic and anxiolytic agent, and it significantly reduces pain associated with transrectal ultrasound guided prostate biopsy. We studied its use in flexible cystoscopy in men younger than 55 years.
A total of 61 patients were prospectively randomized to receive air (31) or Entonox (30). Both groups had 3 minutes of gas via a breath activated facemask (either Entonox or air) before endoscopy. The gel control group was comprised of 8 patients who underwent cystoscopy after instillation of lidocaine gel. The air and Entonox groups had lidocaine gel as per best standard. Vital signs were recorded before, during and after cystoscopy. Patients completed a visual analog score for gel insertion and cystoscopy.
There were no statistically significant differences between the groups in terms of baseline characteristics. Pain scores for cystoscopy (p<0.001) and intraoperative pulse rate (p=0.008) were significantly less with Entonox. Side effects were transient and seen more often with Entonox (p<0.05). More of the air group would require more analgesia (p=0.001) or a general anesthetic (p=0.011) if undergoing repeat cystoscopy.
Nitrous oxide inhalation significantly reduces cystoscopy related pain without significant complications. We propose that Entonox should be the anesthetic agent of choice for men younger than 55 years.
To investigate the effect of chlorhexidine gluconate in urethral local anesthetic gel on patients undergoing outpatient flexible cystoscopy. We postulated that chlorhexidine was contributing to the pain and urgency that occurs during and after cystoscopy.
A prospective randomized single-blinded study was conducted. A total of 141 patients undergoing outpatient flexible cystoscopy participated in the study. They were randomized to receive 10 mL of 2% lignocaine gel with 0.05% chlorhexidine gluconate (group 1, n = 72) or 10 mL of 2% lignocaine and aqueous gel mixture (group 2, n = 69). Pain scores were recorded on a numerical visual analog scale from 0 to 10.
The groups were well matched for the purposes of comparison. The mean pain scores were not significantly different between groups 1 and 2 at the insertion of the scope (2.1 versus 2.2, P = 0.7), during cystoscopy (1.8 versus 1.9, P = 0.759), and immediately after cystoscopy (1.4 versus 0.8, P = 0.06). However, a significant difference was found in the mean pain scores between groups 1 and 2 during the first void (1.8 versus 1.0, P = 0.031) and after the first void (2.4 versus 1.2, P = 0.007). A significant increase occurred in the reported levels of urgency after cystoscopy in group 1 (P = 0.018). No difference was found in the level of culture-proven symptomatic infection.
Chlorhexidine appears to contribute to significant levels of pain and urgency after outpatient flexible cystoscopy.
Advancement of urologic instruments through the genitourinary tract is associated with significant axial forces that likely contribute to patient discomfort, even after injection of a local anesthetic, and may lead to mucosal trauma, postprocedural dysuria and hematuria, and increased susceptibility to infection and strictures. Placing an everting urethral sheath prior to instrumentation may decrease these problems. Materials and
Two 7-cm-long, 5-mm diameter urethral luminal models were created, one with and one without an artificial stricture. We measured the forces generated during advancement of a novel everting access sheath (Cystoglide; Percutaneous Systems, Mountain View, CA) through the models in comparison with a representative cystoscope and a urologic dilator simulating a traditional access sheath.
The mean force generated during advancement of the everting sheath was significantly less than that of both the representative cystoscope (P<0.01) and the traditional access sheath (P<0.01). This held true for the urethral models both with and without an artificial stricture (P<0.01) and with and without lubrication (P<0.01).
This novel introduction sheath markedly decreased the axial forces applied to an artificial urethral luminal wall. It is possible that the clinical use of this technology will decrease the discomfort and potential complications associated with lower urinary-tract endoscopy.
To consolidate previous reports and conduct a meta-analysis to draw further conclusions on the efficacy of the instillation of lidocaine gel before flexible cystoscopy, as it has had varying efficacy in several randomized controlled studies.
We reviewed previous reports cited in PubMed, Biosis and the Cochrane Library, identified by a professional librarian searching for English language-only randomized controlled studies involving the keywords, lidocaine, cystoscopy, gel and pain, yielding 14 studies. Ten studies were excluded as they provided no comparison with appropriate control groups or contained insufficient data for analysis. Attempts to contact the authors of these studies yielded no additional data. A meta-analysis was conducted using a random-effects model.
Four studies were included in the analysis, two double-blind and two single-blind, totalling 411 male patients. Three of the studies found no statistical improvement and one study found a statistically significant improvement in pain relief using lidocaine gel. Studies varied on the quantity of gel instilled and on the dwell time of gel before cystoscopy. The meta-analysis found that subjects who received anaesthetic-impregnated gel were 1.7 times more likely not to experience moderate to severe pain (<2, 3 or 30, based on the scale used; odds ratio 1.7, 95% confidence interval 1.1-2.8) than subjects who did not have intraurethral instillation of gel.
These data suggest that intraurethral instillation of lidocaine gel vs plain lubricating gel reduces the likelihood of moderate to severe pain during flexible cystoscopy.
In current clinical practice, lidocaine gel is widely used as a local anesthetic lubricant before various forms of transurethral instrumentation. Over the past few years, the value of local anesthesia during urethral catheterization and flexible or rigid cystoscopy has been questioned. Strong data are lacking, and the results from the different studies are contradictory. As a result, the correct use of the intraurethral gels is, for the most part, left to individual preference. The purpose of this review is to provide an overview of the characteristics of the intraurethral gels, to assess the effectiveness, and to define evidence-based indications for their use.
To assess the impact on visual analog scale (VAS) pain scores of allowing male patients to view the procedure of flexible cystoscopy.
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.
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.
Real-time visualization of flexible cystoscopy with simultaneous explanation improves male patients' comfort.
The standard technique of a JJ stent removal is with the use of a cystoscope. The distal end of the stent is held in a biopsy forceps and the stent removed by a gentle pull. Stent on a string has been used at the end of a percutaneous nephrolithotomy (PCNL) for the drainage of the ureter. Segmental metallic stents need modifications to the conventional endourological techniques. Encrusted and migrated Memokath stents are difficult to remove. Clearance of the encrustation may be necessary before stent removal. Proximally migrated stents may require percutaneous removal. Functional assessment with renography is necessary if the stent has been indwelling for a long time. Renal function tests and an overall assessment of the patient including coagulation screening is important as the patient may require insertion of a nephrostomy tube prior to the removal of the migrated ureteric stents.
Objective: We evaluate the discomfort and efficacy of instilling 2% lignocaine gel (Instillagel) versus smearing water-soluble gel (Aquagel) around the flexible cystoscope and external urethral meatus in men undergoing flexible cystoscopy for the first time and the overall efficacy of lignocaine gel in completion of the procedure. Materials and Methods: A total of 140 patients divided into two groups, were randomized for this study: group A (n = 70) received approximately 11 ml of 2% lignocaine gel (Instillagel) intraurethrally for approximately 15 min, while in group B (n = 70) approximately 10–15 ml of water-soluble gel (Aquagel) was smeared around the scope and external urethral meatus. Total completion time for each procedure was recorded. Primary outcomes were pain during instillation of lignocaine, during insertion of scope and cystoscopy. Pain was recorded by the patient using a 100-mm nongraphic rating visual analogue scale. Secondary outcome included procedure time and cost analysis. Results: The majority of patients in both groups reported mild pain with VAS 3 or less throughout the whole procedure. No significant difference was noted in the two groups at any stage of the procedure. Use of lignocaine gel added approximately 10 min to the procedure time. Conclusions: In our study there was no significant difference in patient discomfort between instilling lignocaine gel and smearing of Aquagel in completion of flexible cystoscopy. However, application of lignocaine gel added extra time, effort and cost to the procedure.
Purpose:
To assess the impact of listening to preferred music on relieving male patients' pain and anxiety during flexible cystoscopy.
Patients and methods:
A total of 124 male patients were admitted to our hospital for flexile cystoscopy by a single urologist between January 2013 and September 2013 and randomized to two equal groups. Group 2 included 62 patients who could select and listen to their preferred music during flexible cystoscopy. Group 1 included 62 patients who were unable to listen to the music. All patients were administered the same amount of lidocaine (10 mL) for 3 minutes for local anesthesia before flexible cystoscopy. A visual analog scale (VAS) ranging from 0 to 10 was used to assess patients' pain feeling after the cystoscopy procedure. Anxiety levels were calculated according to the State Instrument of State-Trait Anxiety Inventory (STAI-S), and the pulse rate were recorded 5 minutes before and immediately after the procedure. The duration of the procedure of each group were also analyzed.
Results:
Statistically significant differences were detected between group 1 and group 2 in the mean pain score on VAS (2.53 ± 1.34 vs 1.63 ± 1.09, P=0.002, Mann-Whitney U test), mean postprocedural State Anxiety Inventory pain score (39.4 ± 6.5 vs 34.5 ± 5.8), and postprocedural pulse rate (79.8 ± 5.5 vs 76.0 ± 7.3) (P<0.001 for both, t test). Patients who listened to their preferred music experienced less discomfort and lower anxiety at cystoscopy. Patient age, duration of the procedure, preprocedural STAI-S, and preprocedural pulse rate of each group were comparable.
Conclusion:
Listening to preferred music during flexible cystoscopy is an easy way to improves male patients' comfort and reduce their anxiety. It could be recommended for male patients.
Aim:
To determine optimum duration of intraurethral 2% lidocaine jelly for pain relief during outpatient rigid cystoscopy.
Materials and methods:
This prospective randomized study was conducted between June 2012 and November 2013. Four hundred consecutive adult males requiring diagnostic rigid cystoscopy were randomized into four groups depending on intraurethral 2% lidocaine jelly dwell time before rigid cystoscopy: jelly was instilled 5, 10, 15, and 20 minutes before start of the procedure in group A, B, C, and D patients, respectively. The patients' age, patient-reported preoperative anxiety score, patient-reported intraoperative pain score, the surgeon-reported patient's pain score, and the duration of rigid cystoscopy were recorded and analyzed.
Results:
The mean age, patient-reported preoperative anxiety score, and duration of rigid cystoscopy were similar between the four groups with no significant difference noted between them. The least and highest mean patient-reported and surgeon-reported intraoperative pain scores were reported in group C (1.49±0.82 and 1.58±0.67) patients and group A (4.86±1.24 and 4.04±1.11) patients, respectively, while no significant difference was found in these scores between group C and D patients.
Conclusion:
For male patients undergoing diagnostic rigid cystoscopy, an intraurethral dwell time of 15 minutes (of 20 mL 2% lidocaine jelly) provided optimum pain relief.
Background:
Patients undergoing both rigid and flexible cystoscopic evaluation suffer from a great deal of pain and discomfort. In this study, we aimed to investigate the effect of lidocaine gel anestesia on patient comfort on diagnostic rigid cystoscopy.
Material and methods:
11 mL of lubricant gel applied to each patient via the external meatus in 10 s. Patients were randomized into three groups. In group 1, liquid glycerine was applied and cystoscopy was immediately performed, in group 2 lidocaine gel (Aqua Touch™: İstem Tıbbi Cihaz Ve Sanayi Ltd.Şti, Ostim, Ankara, Türkiye) was applied and the procedure undergone immediately and in group 3, lidocaine gel was applied and penis was clemped for 10 minutes before the procedure. VAS forms were filled to determine the discomfort and pain during cystoscopy and the first micturation after.
Results:
After the evaluation between groups, VAS scores were significantly lower in Group II and III than Group I and in Group III than in Group II (p < 0.05). When post micturation VAS scores were evaluated, VAS scores were significantly lower in Group II than Group I and in Group III than in Group II (p < 0.05).
Conclusions:
The application of local anesthetic lidocaine gel in rigid cystoscopy, is a practical, safe and efficient method to improve patient comfort when applied in appropriate dose and waiting duration.
Objective To investigate the role of real-time visualization during flexible cystoscopy in alleviating pain in male patients. Methods A total of 110 male patients under going diagnostic and monitoring flexile cystoscopy were randomized into 2 equal groups. Group A included 55 patients who were allowed to view the procedure on a video monitor; Group B included 55 patients who were not allowed to. All procedures were finished by a single urologist. Patients in both groups were given explanation before cystoscopy, and those in Group A were also given explanation when they were watching the video monitor. The patients'pain feeling was recorded on an VAS (visual analogpain scale) ranging from 0 to 10 after flexible cystoscopy. The pulse and respiratory rate were also recorded. Results The patients in Group A had a significantly lower VAS score than those in Group B (1.29±1.20 vs 3.36±2.46, P<0.001). The postprocedure pulse rate and respiratory rate were not significantly different between the two groups. Conclusion To be allowed to watch the flexible cystoscopy procedure on a video monitor with simultaneous explanation can alleviate pain in male patients.
Das Fachgebiet der Urologie hat wie kaum ein anderes Fachgebiet von der wissenschaftlich-technischen Revolution in der Medizin der letzten 20 Jahre profitiert.
Pain control in outpatient rigid cystoscopy is often achieved via the application of intraurethral lidocaine jelly. This clinical trial was designed to test the effectiveness and safety of a new method to provide local anesthesia, transperineal urethrosphincteric block (TUSB), prior to rigid cystoscopy.
Male patients posted for outpatient rigid cystoscopy were randomized to receive TUSB (group A) using 10-20 ml of 1% lidocaine, intraurethral 30 ml of 2% lidocaine jelly (group B) or intraurethral 30 ml of neutral jelly (group C) as a method of pain control. Following the procedure, plasma concentrations of lidocaine were measured in group A patients. Outcome assessments included mean urethral and sphincteric numerated pain scores (0-10), overall discomfort level (0-4) and plasma lidocaine levels.
One hundred and fifty patients were recruited, 50 in each group. When the three groups were compared, the ratio of group A patients with sphincteric pain score >or=2 was significantly the least. Also, the ratio of group A patients with discomfort level >or=2 was significantly less than the same ratio in either group B or C. Plasma lidocaine concentrations were within nontoxic levels and never exceeded 2.83 microg/ml in 39 subjects.
This study demonstrates that TUSB is an effective and safe method in significantly relieving the pain associated with outpatient rigid cystoscopy. TUSB may offer urologists and anesthetists an alternative way to achieve pain control besides intraurethral lidocaine jelly during rigid cystoscopy.
1The responses of rabbit urinary bladder to hydrostatic pressure changes and to electrical stimulation have been investigated using both the Ussing chamber and a superfusion apparatus. These experiments enabled us to monitor changes in both ionic transport across the tissue and cellular ATP release from it.2The urinary bladder of the rabbit maintains an electrical potential difference across its wall as a result largely of active sodium transport from the urinary (mucosal) to the serosal surface.3Small hydrostatic pressure differences produced by removal of bathing fluid from one side of the tissue caused reproducible changes in both potential difference and short-circuit current. The magnitude of these changes increases as the volume of fluid removed increases.3Amiloride on the mucosal (urinary), but not the serosal, surface of the membrane reduces the transepithelial potential difference and short-circuit current with an IC50 of 300 nm. Amiloride reduces the size of, but does not abolish, transepithelial potential changes caused by alterations in hydrostatic pressure.4Field electrical stimulation of strips of bladder tissue produces a reproducible release of ATP. Such release was demonstrated to occur largely from urothelial cells and is apparently non-vesicular as it increases in the absence of calcium and is not abolished by tetrodotoxin.5It is proposed that ATP is released from the urothelium as a sensory mediator for the degree of distension of the rabbit urinary bladder and other sensory modalities.
The evidence for release of vasoactive substances from endothelial cells in response to shear stress caused by the viscous drag of passing fluids is reviewed and, in particular, its physiological significance both in short-term regulation of blood vessel tone and in long-term regulation of cell growth, differentiation, proliferation, and cell death in pathophysiological conditions is discussed. A new concept of purinergic mechanosensory transduction, particularly in relation to nociception, is introduced. It is proposed that distension of tubes (including ureter, vagina, salivary and bile ducts, gut) and sacs (including urinary and gall bladders, and lung) leads to release of ATP from the lining epithelium, which then acts on P2X2/3 receptors on subepithelial sensory nerves to convey information to the CNS.
To investigate the effect of warming lignocaine on the pain associated with subcutaneous injection.
Double blind, randomised, crossover study.
Hospital clinic.
40 healthy volunteers.
Subcutaneous injection with 1 ml of 1% lignocaine at 20 degrees C and 1 ml of 1% lignocaine at 37 degrees C.
Pain assessed by linear analogue pain scores and subjects' comparison of pain on injection.
25 subjects (89%; 95% confidence interval 72% to 98%) thought that lignocaine at 20 degrees C was more painful and 3 (11%; 2% to 28%) thought that lignocaine at 37 degrees C was more painful (p < 0.0001); 12 subjects did not express a difference. Median pain score for injection at 20 degrees C was 11.00 and at 37 degrees C was 3.25 (p < 0.001). Median difference was 8.25 (4.00 to 13.50).
The simple procedure of warming to 37 degrees C reduced the pain associated with subcutaneous injection of lignocaine.
Emergency physicians often rely on the use of local anesthetic agents to relieve patient discomfort, and research continues in an effort to develop new agents with improved anesthetic qualities. Eventually, a nontoxic, rapidly acting agent may become available that could provide profound anesthesia of long duration when applied topically to intact skin or wounds. Until the "perfect" agent is developed, physicians can help the patient by making knowledgeable choices regarding local anesthetic techniques. By choosing topical agents when appropriate and buffering agents to be infiltrated, using courteous techniques of injection, and being cognizant of potential adverse reactions, the physician can turn a potentially unpleasant and frightening situation for the patient into a positive experience that promotes satisfaction and cooperation.
Local anesthesia by intradermal administration of lidocaine is employed in virtually all interventional radiologic procedures. Transient burning and/or pain are experienced by almost everyone who receives lidocaine by this route. An anecdotal report has recently been published that suggests that warming of lidocaine to 43 °C reduces or eliminates the pain associated with intradermal lidocaine injection. To verify this, we performed a prospective, blinded trial as described below. There was a preference for warm lidocaine over cold lidocaine for intradermal injection. The difference, however, was unimpressive and appeared to be influenced by individual variations in pain perception and by injector or arm preference.
To assess the efficacy and toxicity of bupivacaine as a topical urethral anaesthetic.
This prospective two-part study comprised a pilot study of 10 men (mean age 73 years, range 39-86), to determine the toxicology, pharmocokinetics and suitable preparation of bupivacaine gel, and a study of 40 men (mean age 76 years, range 59-92) to compare the efficacy of bupivacaine with lignocaine gel. All patients were undergoing treatment for benign prostatic hyperplasia by transurethral radiofrequency heating using the Direx Thermex II system.
There were no major adverse events. Bupivacaine provided good topical anaesthesia with a mean duration of 141 min, compared with 29 min for lignocaine. Serum samples taken from patients showed that the drug was absorbed slowly, and with a dose of 50 mg there was a wide margin between serum drug concentrations and toxic levels.
Bupivacaine is safe and effective as a topical anaesthetic agent in the urethra in circumstances where prolonged duration of action is desirable. For lower urinary tract procedures 20-22 mL of anaesthetic gel is required, giving 2-3 h of analgesia/anaesthesia with no significant toxicity or adverse effect. The application of longer-acting anaesthetic agents need not be only during surgical intervention, but might usefully be extended post-operatively to provide early management of pain.
The recent discovery of a P2X purinoceptor (a ligand-gated ion channel triggered by ATP) that is selectively expressed by small-diameter sensory neurons has led to the exploration of the sources of ATP involved in the initiation of different types of nociception and pain, including sympathetic nerves, endothelial cells and tumour cells. In addition, the anti-nociceptive actions of adenosine via prejunctional P1(A1) purinoceptors in the spinal cord and the pain-enhancing actions of adenosine via P1(A2) purinoceptors in the periphery have generated great interest in the development of P1 agonists and antagonists, as well as P2X antagonists as potential analgesic drugs.
The temperature dependence of different indices of axonal excitability (threshold, latency, refractoriness, supernormality, strength-duration time constant, and rheobase) was studied for cutaneous afferents of 8 healthy human volunteers using threshold tracking. Cooling from approximately 32 - approximately 22 degrees C dramatically increased the threshold for a conditioned potential evoked during the relatively refractory period (average increase 573%) but had little effect on the threshold for unconditioned potentials (increased by 4% with 0.1-ms test stimuli), strength-duration time constant (increased by 18%), or rheobase (decreased by 12%). Cooling increased the latency of the unconditioned test potential by 41%, but this slowing was small compared with the effect of cooling on the latency slowing attributable to refractoriness. This measure of refractoriness was initially 0.17 ms at a conditioning-test interval of 2 ms, and increased with cooling to 1.30 ms at the same interval. With cooling, refractoriness was both greater at any one conditioning-test interval and longer in duration, extending into intervals normally associated with supernormality. It is concluded that, although cooling affects all excitability indices to some extent, the most prominent feature is the increase in refractoriness. By contrast, strength-duration time constant is influenced little by temperature.
The evidence for release of vasoactive substances from endothelial cells in response to shear stress caused by the viscous drag of passing fluids is reviewed and, in particular, its physiological significance both in short-term regulation of blood vessel tone and in long-term regulation of cell growth, differentiation, proliferation, and cell death in pathophysiological conditions is discussed. A new concept of purinergic mechanosensory transduction, particularly in relation to nociception, is introduced. It is proposed that distension of tubes (including ureter, vagina, salivary and bile ducts, gut) and sacs (including urinary and gall bladders, and lung) leads to release of ATP from the lining epithelium, which then acts on P2X2/3 receptors on subepithelial sensory nerves to convey information to the CNS.