Office cystoscopy was utilized in the present study to survey the bladder for a variety of indications, most commonly hematuria and recurrent urinary tract infections. Symptoms of dysuria, hematuria, and voiding difficulty following cystoscopy can last several days.3
While alternatives to cystoscopy such as urinary markers continue to be developed, a recent study indicates that patients are reluctant to forego cystoscopy without tests with 95% accuracy or better, such that cystoscopy remains an important surveillance tool.4
Although it is anticipated that less invasive modalities will gain wider acceptance, it is important to evaluate methods of minimizing morbidity related to office cystoscopy.
Prior studies evaluating flexible and rigid cystoscopy have focused on complications, tolerability, and effectiveness. Previous studies have demonstrated equal efficacy between rigid and flexible cystoscopy in identifying tumors.5,6
Earlier comparisons revealed male patients preferred flexible cystoscopy in the clinic rather than rigid cystoscopy in the operating room with general anesthesia.7,8
Further, these evaluations could be safely performed without the use of routine antibiotics.9,10
Our current study is unique in that our data were obtained in the form of a randomized, patient-blinded trial in an attempt to minimize bias. Furthermore, this study is the first to focus on tolerability of cystoscopy in women in the outpatient ambulatory setting. Overall, both techniques are well tolerated by women with pain scores of 1.4 versus 1.8 out of 10 for flexible and rigid cystoscopy respectively. In contrast, flexible cystoscopy in men is better tolerated than rigid cystoscopy, presumably due to urethral length and the angle required to inspect the bladder. In general, excellent tolerability was noted with both techniques with the majority of women reporting minimal discomfort on the VAS. High tolerability is demonstrated elsewhere in the literature. In another study,4
60% of women reported pain less than 2 on a VAS when evaluated after flexible cystoscopy.
It should be noted that most of the patients in this study [14/22 (61%)] had previously undergone cystoscopy, which may have affected their perception of discomfort. It is noteworthy that only 1 out of 10 patients undergoing flexible cystoscopy with previous rigid cystoscopy experience actually preferred rigid cystoscopy, whereas 4 preferred flexible cystoscopy and 5 had no preference. Furthermore, with flexible cystoscopy, women may be positioned supine in a frog-leg position which could be advantageous in the office setting. As has been shown previously,5
performing cystoscopy with the patient in the supine position can decrease preparatory and procedural time. Because differences in positioning could potentially influence perceptions of pain or discomfort, in our study cystoscopy was performed with the patient in the dorsal lithotomy position to avoid any potential bias in this regard and to maintain blinding for both flexible and rigid techniques. This study was not actually designed to evaluate time elapsed in cystoscopy, although it may follow that with the use of 1 scope as opposed to 2, the flexible procedure may be faster. This study was also not designed to evaluate the role of local anesthetic in cystoscopy, given recent studies including a metaanalysis of 9 randomized trials indicating no difference in pain perception in patients with local anesthetic versus sterile lubricant alone.11,12
Draping in the cystoscopy suite to permit patient blinding to flexible versus rigid cystoscopy.
In addition to technique, several other aspects of office cystoscopy have been evaluated in relation to patient discomfort, which could potentially confound our findings. For instance, administration of midazolam has been found to be effective in lessening patient discomfort. In this randomized trial,13
patients were divided into groups in which either flexible or rigid cystoscopy was performed in men and women, although the trial, designed to determine the effectiveness of midazolam, did not directly address flexible versus rigid cystoscopy. Another factor that may be significant in affecting patient discomfort is whether patients can observe the monitor during cystoscopy.14
Patient age has also been cited as an important factor in that older patients are generally better able to tolerate cystoscopy.15
Cost may be another consideration in comparing these 2 techniques. Although patient preparation and maintenance costs for rigid and flexible cystoscopy are similar, the purchase price for rigid cystoscopes can be 2 to 3 times less than that for flexible cystoscopes.13
However, flexible scopes are quite durable with reasonable repair costs.16