Does visualisation during urethrocystoscopy provide pain relief? Results of an observational study

In our observational study we investigated the differences in pain during urethrocystoscopy between patients who could watch their procedure on a real-time video screen and patients who could not in an everyday clinical setting. We found that only men who underwent flexible urethrocystoscopy and wanted to watch their procedure on a real-time video screen perceived their urethrocystoscopy as significantly less painful. For other patients this effect was not observed. Furthermore, women who underwent urethrocystoscopy have significantly more pain than men.

To our knowledge only a few studies so far have examined the impact of real – time visualisation on pain perception during urethrocystoscopy. Clement et al. [8] conducted a prospective randomized study in 2004 with patients who had flexible urethrocystoscopy. Four further randomised studies on male patients who underwent flexible urethrocystoscopy were conducted by Patel [9] in 2006, Cornel [14] in 2007, Soomro [10] in 2010 and Zhang [11] in 2011. Patel also analysed the impact of real – time visualisation on pain in women who underwent rigid urethrocystoscopies in another randomised study in 2008 [15].

So far only Clements et al. [8] showed the impact of real – time visualisation on urethrocystoscopy on patients of both genders.

A number of differences between the randomised controlled studies and this observational study make direct comparison difficult.

First, in our study we used a numeric rating scale 0 to 10 to measure perceived pain. Patel et al. used a 100 mm visual analogue scale in both of his studies [9, 15]. Clements et al., Cornel et al., Soomro et al. and Zhang et al. used a visual analogue scale 0 to 10 [8, 10, 11, 14]. According to Williamson et al.’s review on pain scales both scales provide the same information but cannot be converted into one another [16]. Given that the different scales transfer the same information the results of the different studies can be compared.

Second, inclusion and exclusion criteria were different in the studies mentioned. In order to best approximate everyday clinical practice our exclusion criteria were broadly defined as the use of general or local anaesthesia and analgesics. In the other studies exclusion criteria were more narrowly defined [8‐11, 14, 15].

Third, different numbers of urologists performed urethrocystoscopies on the included patients. In Soomro study and our study more than one urologist performed the urethrocystoscopy, so that the results would not be limited to the skill of one person [10]. In Clements et al., Patel et al. and Zhang et al. studies only one urologist performed the procedure [8, 9, 11]. We think both approaches could include possible bias. Assessing the results of more than one urologist mixes different skills and difference in performance which might influence pain. Limiting the results to the performance of one urologist means that the pain score can only be related to this one urologist’s performance. We decided to have more than one urologist perform urethrocystoscopy as it is closer to everyday clinical practise, even though we are aware that this approach might include possible bias. As this study was done in an outpatient clinic to assess pain during urethrocystoscopy in everyday clinical practise, we believed the results could be better related to everyday clinical practise if more than one urologist performed the procedure.

The greatest limitation of our study is that it was not randomised. Patients could choose whether they wanted to observe their own urethrocsytoscopy or not. Pain is a very subjective parameter. Therefore, it is difficult to assess and to generalise [17]. We tried to create the most comfortable setting for our patients, which included letting them choose what they felt most at ease with. In letting the patient choose whether they wanted to watch the procedure on a real-time screen, we were closer to everyday clinical practice, where no patient who does not want to watch his or her own procedure on real time video is forced to do so.

Our data showed that visualisation on a real-time screen does not make urethrocsytoscopy less painful for patients in general. Kesari et al. investigated the role of visualisation on a real-time video screen with thorough explanation during the procedure [18]. In this small cohort (n = 51) patients who watched their procedure real time on a video screen did not benefit regarding their anxiety or their pain. In this study visualisation was examined as an addition to explanation and not as a measure to decrease pain on its own [18].

Focusing on flexible urethrocystoscopies our results confirm the results found by Clements et al., Patel et al., Soomro et al. and Zhang et al. [8‐11]. Men who are able to watch their urethrocystoscopy in real-time on a video screen find it significantly less painful. Cornel et al.’s results oppose these findings [14]. Soomro et al. suggested that this might be due to the fact that the lithotomy position is less comfortable than the supine position [10] In Zhang et al.’s study and in our observational study all patients were examined in the lithotomy position, nevertheless our results showed that the procedure was significantly less painful for those who could watch it on a real – time video screen. Cultural differences between European and American men are offered as a possible explanation [11]

In our patient cohort only 2 women had flexible urethrocystoscopy. Therefore based on this data no assumptions can be made about the effect real time visualisation has on pain during flexible urethrocystoscopy on women. This might be due to the recommendations regarding flexible urethrocystoscopy on women based on the recent findings of Gee et al. and Quiroz et al. [19, 20]. They state that there is no difference in comfort for women regardless of whether or not a rigid or a flexible instrument is used. For rigid urethrocystoscopies our results concerning women were similar to those of Patel et al. regarding the use of real-time visualisation in women who had rigid urethrocystoscopies. It has to be pointed out, that our observational study also included men who had rigid urethrocystoscopies. But as only two men did not watch their rigid urethrocystoscopy on a real-time video screen, no valid statistical analysis could be performed.

Cornel et al. found that patients who had experience with urethrocystoscopy did not find it more comfortable than those who had not [14]. We found that patients who had had urethrocystoscopy before had significantly less pain than those who did not. These finding are in line with recently published data in over 1300 consecutive procedures showing that pain levels during first cystoscopy is higher than for repeated cystoscopies [21]. Again, this might be due to cultural differences but it could also be due to the smaller number of patients Cornel et al. included in their study. Anatomy suggests that urethrocystoscopy should be more painful for men than for women given the difference in length of the urethra. In our observational study this was not the case. Women experienced significantly more pain than men. This suggests that the invention of flexible urethrocystoscopy made the procedure more comfortable for men. No such benefit occurred in women. Patel et al. presume that this is the case because women are not able to visualise the most painful part of urethrocystoscopy: the passage of the urethra as it is performed blindly in women [15]. It is however not clear what the most painful part in urethrocystoscopy on women is, because the study generated by Taghizadeh et al. included only men [22]. To our knowledge, no such study about the most painful part in urethrocystoscopy in women exists. As Patel et al. points out, there is probably more than one factor that makes urethrocystoscopy more painful for women [15]. The results of a recent study suggest that by using flexible instruments it is possible to reduce pain in women during flexible urethrocystoscopy [21]. Therefore the use of a flexible instrument on women should be encouraged.