In women with bladder pain, we should look out for inflammatory changes, including glomerulations, which can suggest interstitial cystitis.
We also have the option of performing cystoscopy under anesthesia for patients with bladder pain. This process enables us to hydrodistend the bladder—the bladder is filled with fluid to capacity, emptied, and refilled—for an examination both of bladder capacity and of abnormalities like bleeding from glomerulations, while eliminating the pain component. A bladder that holds less than 400 mL of fluid under anesthesia is a bladder that is chronically scarred.
Bladder biopsies can be performed at the time of hydrodistention. Unfortunately, there is no consensus on indications for biopsy or on criteria for diagnosing interstitial cystitis (indeed, much about interstitial cystitis is controversial), but I believe that the scope can be an important diagnostic tool.
There also often is a therapeutic benefit to performing a cystoscopy and hydrodistention under anesthesia: Many patients remain relatively free of pain for 6 months or longer after the procedure. The urethral pain and dysuria that sometimes occur with cystoscopy can be treated with a preprocedure intraurethral injection of lidocaine jelly or oral phenazopyridine (Pyridium). Prophylactic oral antibiotics should be given routinely either right before or right after the procedure.
Intraoperative Cystoscopy
With more advanced incontinence and prolapse surgeries being performed by both urologists and gynecologists, it has become ever more important to use intraoperative cystoscopy to ensure that the bladder and ureters remain undamaged and unobstructed. In fact, we have reached a point where cystoscopy should be performed routinely for most advanced pelvic reconstructive procedures, whether the procedures are done vaginally or abdominally.
It is absolutely imperative that cystoscopy be performed with every retropubic sling that uses the tension-free vaginal tape (TVT) procedure.
With transobturator tape (TOT), its necessity is more debatable because needles don't pass as close to the bladder. Surgeons who have comfortably and successfully performed a significant number of TOT procedures can probably forgo cystoscopy.
There is one exception, however: cases in which TOT is performed before the prolapse is repaired. In this case, cystoscopy remains imperative.
Intraoperative cystoscopy has a fringe benefit as well, in that it sometimes leads to the identification of pathology—bladder stones, for instance—that went undiagnosed during the preoperative work-up.
Cystoscopy can also be used to guide the placement of suprapubic catheters intraoperatively, although its most significant purpose is to document ureteral patency. When examining for patency, most surgeons inject indigo carmine intravenously and examine the bladder approximately 10 minutes later to document flow of the dye through both ureteral openings.
Instruments and Training
A urethroscope with a 0-degree lens allows appropriate examination of the urethra; however, a 70-degree lens is preferable for examination of the bladder because it enables visualization of the entire circumference of the bladder in more detail.
Some surgeons are using flexible cystoscopes—the optics of flexible cystoscopy have improved significantly in recent years—but the 70-degree rigid scope is sufficient in the vast majority of procedures.
Gynecologists who perform trans- or periurethral bulking agent injections for intrinsic sphincteric deficiency must be comfortable with using a 0-degree scope in the office. In this process, which typically is done under cystoscopic guidance, a needle is placed either through the cystoscope or lateral to the urethra, and the agent—collagen (Contigen), silicone (Macroplastique), carbon beads (Durasphere), or another agent—is injected to add bulk around the urethral lumen and to increase urethral resistance.
For many gynecologists, cystoscopy is a natural progression from hysteroscopy. The two procedures are very similar when used for diagnostic purposes. Others are starting to perform cystoscopy even without the background in hysteroscopy, however.
In any case, the main issue we face is the need for training. We must learn how to use the instrumentation and advance the scope safely, without causing bladder trauma or perforation; how to approach various indications; and how to judge abnormal and normal aspects of the images obtained.
Although there are no courses including certification at this time, ACOG and others do offer various training courses designed to allow ob.gyns. to develop an expertise in cystoscopy.
Bladder trabeculations are in a patient with overactive bladder.
Urethral changes reflecting different levels of estrogenation: Atrophic looks pale and flat (top), normal looks pink and spongy (bottom). Photos courtesy Dr. G. Willy Davila
Tension-free vaginal tape mesh is shown in the urethra.
Ureteral opening is shown via cystoscopy, after injection of indigo carmine dye to document ureteral integrity. Photos courtesy Dr. G. Willy Davila
Cystoscopy
As a physician on the teaching faculty of two different residency programs in metropolitan Chicago—and as one whose surgical practice is limited to minimally invasive techniques—I see residents rotating through my service routinely performing cystoscopy in conjunction with total laparoscopic hysterectomy, resection of deep endometriosis over the pelvic sidewall or bladder, placement of a sling for the treatment of stress urinary incontinence, or evaluation of the bladder for interstitial cystitis.