STONE DISEASE

Impact of real-time visualization of cystoscopy findings on procedural pain in female patients
Patel AR, Jones JS, Babineau D
Glickman Urological and Kidney Institute, The Cleveland Clinic, Cleveland, Ohio 44195, USA
J Endourol. 2008; 22: 2695-8

• Background and Purpose: We have previously shown that men tolerate office flexible cystoscopy better when they simultaneously view the monitor during their procedure. We sought to demonstrate similar effects of distraction on women undergoing rigid office cystoscopy.
• Patients and Methods: 100 consecutive women underwent diagnostic office based rigid cystoscopy. All patients consented to inclusion in the study. Patients were randomized to two groups. The study group consisted of patients who were allowed to view their procedure real-time on the video monitor. The control group patients had the video screen positioned such that only the surgeon could visualize the procedure. Patients underwent rigid cystoscopy using a 17F cystoscope introduced with an obturator. Water-soluble lubricant was liberally applied to all cystoscopes immediately before the procedure. Patients who needed additional procedures, including cystodiathermy or stent extraction, were excluded from the study groups. Postprocedure, patients were asked to record their experience on a 100-mm visual analog pain scale as soon as the surgeon left the room.
• Results: Women who were able to view their cystoscopy findings simultaneously during the procedure did not demonstrate lower pain scores compared with those who did not view the screen (median pain score of 19 v 10; P = 0.16, based on Wilcoxon rank sum test).
• Conclusions: In contrast to the decreased pain scores demonstrated when tested in men, use of distraction by allowing patients to simultaneous view their procedure may not affect procedure tolerance for women undergoing office-based rigid cystoscopy.
  
  
• Editorial Comment
  The authors present a well-designed and conducted randomized prospective clinical trial to evaluate the impact of video-endoscopic visualization on procedural pain during rigid cystoscopy in females. They do not report if a power analysis was conducted - it is possible that a Type 2 error may be encountered due to small sample size.
  The authors have previously reported decreased pain scores in men undergoing flexible cystoscopy when the patients are allowed to visualize the cystoscopic findings on the video tower. As the authors note, the lack of a difference in pain scores in women may be related to the use of rigid cystoscope or positioning in a lithotomy as opposed to supine position.
  It would be helpful to document at what point during the procedure did the women report the most discomfort - if during insertion, this would support the hypothesis that the use of an obturator during blind insertion of the cystoscope eliminates the value of visualization during the procedure. Alternatively, if discomfort was reported during filling with irrigant, was this more common in women with voiding dysfunction and did it correlate with the volume of irrigant instilled or patient’s bladder capacity?
  It would be important to exclude patients who have previously undergone cystoscopy - as pre-procedural anxiety has been reported to correlate with procedural pain. It would be interesting to repeat the study in men using a television show as a sham control - is it distraction that diminishes pain, or is it “visual feedback” that facilitates relaxation as the scope is passed through the bulbar, membranous and prostatic urethra?

Dr. Manoj Monga
Professor, Department of Urology
University of Minnesota
Edina, Minnesota, USA
E-mail: endourol@yahoo.com