Unit Seven: Cystoscopy

After having a clinical assessment, one should be able to exclude the usual pathologic causes of symptoms by going trough history, examination and suitable investigations. More often than not, one should be able to make a diagnosis and start a trial of medical management. However, it might be wise to do a cystoscopy to prove the diagnosis to oneself and also to the patients anxious relatives. More often than not , some one would have already  done a cystoscopy with ‘Normal’ result.  Cystoscopy done under local anesthesia is usually inconclusive as the patient and the clinician both are struggling. The bladder cant be filled to its capacity to inspect all the details as the patient may have intense pain during distension. Hence the cystoscopy should be done under general anesthesia in order to:

  • Be kind to the patient with already a painful condition
  • To be able to distend the bladder completely so as to inspect it better
  • To take a biopsy of a suspicious lesion
  • To perform hydrodistension
  • To ablate any Hunners lesion

Cystoscopy should be done at low pressure and medium volume in order to look for any Hunner’s lesions and Glomerulations .  Typically Hunner’s lesions appear on the mobile portion of bladder and appear to be star shaped pale areas surrounded by radially aligned capillaries. the  center of the lesion may have a fibrinous deposit or a plaque. This disrupts on filling the bladder to its capacity and causes bleeding.

Glomerulations are tiny hemorrhagic spots in the sub urothelial layer and look like bunches of red spots.

The Hunner’s lesions should be ablated by electrocautery by coagulative current. Resection of these lesions with TUR working element has been recommended by some experts.

Hydrodistension is done by allowing the bladder to distend under a pressure of 80 cm of irrigant. The duration of distension should be just sufficient for the bladder mucosa to be stretched, which is usually 1-2 minutes. Longer duration of distension can lead to perforation of bladder.

Decompression of bladder usually leads to diffuse bleeding, which appears as ‘Raining of Blood’

 Hydrodistension works by disrupting the pain carrying nerve endings and increase the physical capacity of the bladder. The beneficial effects of hydro distension last for few months and it may need to be repeated.

Cystoscopic findings classified ESSIC

  • Grade 0: normal mucosa
  • Grade I: normal mucosa with few petechial hemorrhages
  • Grade II: large sub mucosal bleeding (ecchymosis)
  • Grade III: diffuse global mucosal bleeding
  • Grade IV: mucosal disruption with or without bleeding.

 Hemostasis with electro cautery should be done and the bladder drained overnight with a catheter.

Biopsy of the lesion usually is not required and is recommended only if diagnosis is in doubt or for academic interest.

Lets understand the treament of these patients >>