A prospective, randomized, double-blind study comparing lignocaine gel and plain lubricating gel in relieving pain during flexible cystoscopy

Pain reduction methods during transurethral cystoscopy

Transurethral cystoscopy (CS) is a common urological procedure, performed mostly for diagnostic but also for therapeutic purposes. Although CS is generally well tolerated, some patients describe the pain related to the procedure as high or even “unbearable”. As a result, many patients fear and avoid both primary and/or follow-up cystoscopies. This may lead to uncontrolled progression of neoplastic disease. Therefore, it is crucial to maximally increase the comfort of the patient and to implement safe and effective analgesia before the procedure. Providing the patients with appropriate care during CS can encourage them to comply with diagnostic schedules and improve their prognosis. The aim of this review is to analyze the available literature on various methods of pain reduction during transurethral CS. The PubMed electronic database limited to English articles published until January 2021 was used in the process. Meta-analyses, systematic reviews, randomized controlled trials, clinical trials, prospective randomized studies, multicenter comparisons, reviews and retrospective comparisons were used. As a result, 65 articles were included in this review.

Lidocaine lubricant jelly does not reduce pain perception during female urethral catheterization: A systematic review with meta-analysis and trial sequential analysis

OBJECTIVE

The use of lubrication before performing urethral catheterization has been recommended. However, the benefit of using lidocaine gel over plain lubricant gel in reducing pain perception during female urethral catheterization is unclear. With this review, we aimed to compare the pain perception during female urethral catheterization with or without lidocaine lubricant gel.

METHODS

In this study, we systematically searched PubMed, Scopus, Embase, and Web of Science to identify randomized controlled trials (RCTs) comparing 2% lidocaine gel and plain lubricant gel in reducing pain perception during female catheterization. Standard Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed while conducting this review (CRD42020207312).

RESULTS

In this review, six RCTs with 464 participants were included. The overall risk of bias for these studies was low. Pain score was presented as standard mean difference (SMD) with a 95% confidence interval (CI). In the overall and subgroup analysis (according to types of pain scores) no significant difference was found between the use of lidocaine and plain lubricant jelly (SMD -0.24 95% CI [-0.96 0.47]). On trial sequential analysis (TSA), by setting alpha = 5% and beta = 20% for moderate evidence the information size calculated was 440 participants. The cumulative Z-score crossed the TSA line proving the reliability of the results. According to Grading of Recommendations Assessment, Development and Evaluation, the evidence is "moderately" certain.

CONCLUSION

The use of 2% lidocaine gel in female catheterization does not provide a significant reduction in pain perception as compared to plain lubricant gel.

Discomfort and relieving factors among patients with bladder cancer undergoing office-based cystoscopy

OBJECTIVE

To evaluate the degree of discomfort among patients with bladder cancer undergoing office-based cystoscopy and identify factors and interventions that influence discomfort and anxiety.

METHODS

We conducted a survey of the Bladder Cancer Advocacy Network Patient Survey Network (BCAN PSN) to investigate the degree of discomfort associated with office-based cystoscopy and prevalence of interventions used to reduce discomfort. All patients had undergone at least one previous cystoscopy. Bivariable and multivariable logistic regression were used to identify factors associated with moderate-to-severe cystoscopy discomfort.

RESULTS

Among 488 BCAN PSN respondents (50% response rate), 392 responded with demographic data and discomfort score. Cystoscopy was associated with moderate-to-severe discomfort in 52% of patients. Respondents who reported moderate-to-severe discomfort were more likely to describe their most recent cystoscopy discomfort as worse than prior (P<0.001) and to be interested in planning discomfort mitigation for cystoscopy (P<0.001). On multivariable analysis, gender was the only factor independently associated with discomfort, with women reporting less discomfort than men (OR 0.59, 95%CI 0.37-0.95,P=0.03). Patients reported a wide variety of cystoscopy-specific interventions with differing perceived effectiveness, the most common being intraurethral lidocaine.

CONCLUSIONS

Over half of patients undergoing office-based cystoscopy for bladder cancer report moderate-to-severe discomfort, constituting a substantial problem among patients undergoing the procedure. Future large pragmatic comparative effectiveness trials are needed to better understand which interventions work most effectively to reduce discomfort associated with cystoscopy.

Does instillation of lidocaine gel following flexible cystoscopy decrease the severity of post procedure symptoms? A randomised controlled trial assessing the efficacy of lidocaine gel post flexible cystoscopy

Objective

To assess whether instillation of lidocaine gel both before and after flexible cystoscopy is more effective at reducing post procedural symptoms than instillation of lidocaine gel pre flexible cystoscopy alone. We hypothesise that inadequate urethral dwell time and dilution of lidocaine gel by the irrigation fluid during flexible cystoscopy limits its anaesthetic efficacy. Only one other study has attempted to reduce bothersome urinary symptoms through an intervention after flexible cystoscopy.

Methods

This was a randomised controlled trial in which patients were randomised 1:1 to receive lidocaine gel pre and post flexible cystoscopy (treatment) or lidocaine gel pre flexible cystoscopy only (control). Patient-reported outcome measures were used to assess symptoms and quality of life prior to cystoscopy, on day 2 and day 7 post cystoscopy.

Result

Fifty patients were divided equally between the treatment and control groups. There were no significant differences in baseline characteristics between the groups (p = 1.000). An overall symptoms variable was measured, though no significant difference was found in the distribution of responses between the groups at baseline, 2 or 7 days after the flexible cystoscopy (p = 0.423, 0.651,0.735). In the treatment group, 1 patient (4.0%) presented to a doctor for review following flexible cystoscopy, and 4 patients (16.0%) presented in the control group (p = 0.349).

Conclusion

Initial study results suggest that post-operative lidocaine does not significantly limit the exacerbation of urinary symptoms following flexible cystoscopy; however, our results are not powered to detect a small difference. We do not recommend a change in practice based on our results.

The effect of office based flexible and rigid cystoscopy on pain experience in female patients

Purpose

Rigid and flexible cystoscopies are both routinely used in female patients. Literature is conflicting whether flexible cystoscopy is less painful compared to rigid cystoscopy. The aim of this study was therefore to investigate whether using flexible cystoscopy leads to less discomfort and pain compared to rigid cystoscopy in female patients who underwent first time cystoscopy.

Materials and Methods

One hundred eighty-nine female patients, who never had undergone cystoscopy, were randomized into 2 groups: 92 patients underwent rigid cystoscopy and 97 patients flexible cystoscopy. Directly after the cystoscopy procedure all patients were asked to fill out their pain experience on a 100-mm visual analogue pain scale (VAS).

Results

Median VAS score was significantly lower for women undergoing flexible cystoscopy (0 [0–20]) compared to rigid cystoscopy (15 [0–38], p<0.001). In addition, age was inversely associated with VAS score, indicating that younger females experienced more pain (R=−0.30, p=0.001). The use of flexible cystoscopy was associated with a decrease in VAS score and remained significant after adjustment for age, sex of urologist, performing urologist and indication (standardized β=−0.17, p=0.048).

Conclusions

The use of flexible cystoscopy resulted in a significantly lower pain experience compared to rigid cystoscopy. Based on patient's pain experience during cystoscopy, this study implicates to use flexible cystoscopy in female patients who undergo first time cystoscopy.

[Local analgesia during flexible cystoscopy in male patients: A non-inferiority study comparing Xylocaine® gel to Instillagel® Lido]

INTRODUCTION

Local anesthesia using urethral gel has been proven to reduce discomfort of male patients during flexible cystoscopy. This study was a non-inferiority study between two lidocain-containing urethral gel (Instillagel^® Lido and Xylocaine^® gel).

METHODS

A prospective single center study was conducted between June 2014 and November 2014. Male patients seen in the office and in whom a flexible cystoscopy was planned were included in the present study and received urethral instillation of either Xylocaine^® gel or Instillagel^® Lido at least 5minutes before flexible cystoscopy. No other anesthetic agent was used. Primary endpoint was pain during the procedure, assessed through visual analog scale (VAS) from 0 to 10.

RESULTS

Four hundred and sixty-one men were included: 233 in the Instillagel^® Lido group and 228 in the Xylocaine^® gel group. Indications of flexible cystoscopy non-muscle invasive bladder cancer follow-up in 44 % of cases, hematuria work-up in 21 % of cases and lower urinary tract symptoms work-up in 35 %. Patients' age was comparable betwwen both groups: 64.5 years (±1.1) in the Instillagel^® Lido group and 66.2 years (±1.1) in the Xylocaine^® gel group (P=0.29). The mean VAS was 0.8 (±0.1) in the Instillagel^® Lido group and 0.6 (±0.1) in the Xylocaine^® gel group (P=0.10). The non-inferiority criterion was reached (P<0.001) as the average difference in VAS between the two groups was 0.2 with a confidence interval not comprising 1 (CI 97.5 %: -0.47; 0.07).

CONCLUSION

In this prospective study, Instillagel^® Lido was not inferior to Xylocaine^® gel for local analgesia during flexible cystoscopy in male patients.

LEVEL OF EVIDENCE

4.

2% Lidocaine gel or plain lubricating gel: Which one should be used in male flexible cystoscopy?

OBJECTIVE

To investigate and compare the effects on pain of intraurethral 2% lidocaine gel and plain lubricating gel in male patients underwent flexible cystoscopy.

MATERIAL AND METHODS

The data of 220 male patients who underwent flexible cystoscopy between March 2012 and August 2014 were retrospectively analized. The patients were divided into 2 groups according to using intraurethral gel types. Group I included 120 patients who were underwent flexible cystoscopy with 2% lidocaine gel and Group II was consisted from 100 patients who underwent flexible cystoscopy with plain lubricating gel. The groups were compared according to postprocedure data including pain score, procedure time and age of patients.

RESULTS

The mean age of the patients in Group I was 50.02±11.87 years while that in Group II was 52.03±13.37 years (p=0.492). The mean procedure times were 6.02±0.787 and 6.28±0.689 minutes in Group I and Group II respectively (p=0.061). Pain perception scores were not statistically different between the groups (Group I: 3.10±0.980, Group II: 3.34±0.789, p=0.132).

CONCLUSION

Use of intraurethral 2% lidocaine gel has no advantage over plain lubricating gel in regard to pain control during flexible cystoscopy in men.

NaHCO3-Buffered Lidocaine Gel for Outpatient Rigid Cystoscopy in Men

PURPOSE

The purpose of this study was to explore the effect of NaHCO3-buffered lidocaine gel as a topical anesthetic agent for pain relief for rigid cystoscopy.

DESIGN

Prospective randomized controlled trial.

METHODS

ASA I-II male patients undergoing rigid cystoscopy randomly received 10 mL 2% Carbocaine lidocaine gel with 1 mL 0.9% saline (group 1) or 1 mL 5% NaHCO3 solution (group 2). After 3 minutes exposure, the cystoscope was inserted into the urethra. On receiving the gel, cystoscope insertion, and intravesical observation, pain score was recorded using the visual analog scale.

FINDINGS

The gel pH with or without NaHCO3 was 7.20 and 6.41, respectively. The concentration of soluble lidocaine in the gel was stable for 24 hours or more. The visual analog scale score in group 2 was significantly lower (1.3 ± 0.9) than in group 1 (5.28 ± 1.99). No adverse effects were recorded.

CONCLUSION

Alkalized lidocaine gel resulted in successful analgesia for rigid cystoscopy in men without adverse effects.

Does sodium bicarbonate reduce painful voiding after flexible cystoscopy? A prospective, randomized, double-blind, controlled trial

OBJECTIVE

• To determine if sodium bicarbonate (Ural) reduces painful voiding after flexible cystoscopy.

PATIENTS AND METHODS

• 300 patients over 18 years old undergoing elective flexible cystoscopy were enrolled in a randomized, double-blinded, placebo-controlled trial. Patients with active urinary tract infections, indwelling urinary catheters and/or requiring additional procedures such as biopsy and dilatation were excluded. • Painful voiding was quantified using a pain analogue scale from 0 to 10. Pre-existing painful voiding, previous experience with Ural and flexible cystoscopy were recorded. • Flexible cystoscopy was performed to a standard protocol. Patients were randomised after recruitment to receive Ural or placebo (glucose) powder four times a day for two days after the procedure. Trial outcome was assessed by estimating the change in pain incidence and severity from before to two days after by post-procedural questionnaire.

RESULTS

• Painful voiding was present in 84 of the 300 patients post flexible cystoscopy (45 of 160 patients receiving Ural; 39 of 140 receiving placebo), but overall mean pain scores were low (1.25; standard deviation 2.4; on a 0-10 scale). • Treatment with Ural compared to placebo was associated with a non-significant reduction in frequency of pain (28.9% vs 31.3%; incidence rate ratio 0.66; 95% CI 0.29-1.46; P = 0.30) and severity of pain (odds ratio 0.72; 95% CI 0.30-1.74; P = 0.47).

CONCLUSION

•In the replicable context of low post-cystoscopy pain levels, we believe Ural does not reduce painful voiding after flexible cystoscopy.

Meta-analysis: does lidocaine gel before flexible cystoscopy provide pain relief?

OBJECTIVE

To consolidate previous reports and conduct a meta-analysis to draw further conclusions on the efficacy of the instillation of lidocaine gel before flexible cystoscopy, as it has had varying efficacy in several randomized controlled studies.

METHODS

We reviewed previous reports cited in PubMed, Biosis and the Cochrane Library, identified by a professional librarian searching for English language-only randomized controlled studies involving the keywords, lidocaine, cystoscopy, gel and pain, yielding 14 studies. Ten studies were excluded as they provided no comparison with appropriate control groups or contained insufficient data for analysis. Attempts to contact the authors of these studies yielded no additional data. A meta-analysis was conducted using a random-effects model.

RESULTS

Four studies were included in the analysis, two double-blind and two single-blind, totalling 411 male patients. Three of the studies found no statistical improvement and one study found a statistically significant improvement in pain relief using lidocaine gel. Studies varied on the quantity of gel instilled and on the dwell time of gel before cystoscopy. The meta-analysis found that subjects who received anaesthetic-impregnated gel were 1.7 times more likely not to experience moderate to severe pain (<2, 3 or 30, based on the scale used; odds ratio 1.7, 95% confidence interval 1.1-2.8) than subjects who did not have intraurethral instillation of gel.

CONCLUSIONS

These data suggest that intraurethral instillation of lidocaine gel vs plain lubricating gel reduces the likelihood of moderate to severe pain during flexible cystoscopy.

Nitrous oxide inhalation to improve patient acceptance and reduce procedure related pain of flexible cystoscopy for men younger than 55 years

PURPOSE

Flexible cystoscopy in men younger than 55 years is painful despite the current best standard anesthesia (20 ml 2% lidocaine gel 15 minutes before endoscopy). The anesthetic value of lidocaine gel is debated and led us to seek an alternative. Nitrous oxide is a well established analgesic and anxiolytic agent, and it significantly reduces pain associated with transrectal ultrasound guided prostate biopsy. We studied its use in flexible cystoscopy in men younger than 55 years.

MATERIALS AND METHODS

A total of 61 patients were prospectively randomized to receive air (31) or Entonox (30). Both groups had 3 minutes of gas via a breath activated facemask (either Entonox or air) before endoscopy. The gel control group was comprised of 8 patients who underwent cystoscopy after instillation of lidocaine gel. The air and Entonox groups had lidocaine gel as per best standard. Vital signs were recorded before, during and after cystoscopy. Patients completed a visual analog score for gel insertion and cystoscopy.

RESULTS

There were no statistically significant differences between the groups in terms of baseline characteristics. Pain scores for cystoscopy (p<0.001) and intraoperative pulse rate (p=0.008) were significantly less with Entonox. Side effects were transient and seen more often with Entonox (p<0.05). More of the air group would require more analgesia (p=0.001) or a general anesthetic (p=0.011) if undergoing repeat cystoscopy.

CONCLUSIONS

Nitrous oxide inhalation significantly reduces cystoscopy related pain without significant complications. We propose that Entonox should be the anesthetic agent of choice for men younger than 55 years.

Lack of local anesthetic properties of lidocaine gel in an experimental model

INTRODUCTION

Many reports negate the anesthetic properties of lidocaine gel placed in the urethra during catheterization. The anesthetic action of lidocaine is inseparably associated with the toxic action of this compound on cells.

MATERIALS AND METHODS

A primary rabbit urothelial cell culture (PRUCC) was previously established as a monolayer. The effect of 2% lidocaine gel on the viability of the PRUCC was assessed and compared with the cytotoxic effect of decreasing concentrations of lidocaine solution. Cell viability was evaluated after 1-hour exposure using the trypan blue exclusion test.

RESULTS

The 2% lidocaine gel did not show cytotoxic properties after 1 h of incubation on a PRUCC. The 2 and 1% lidocaine solutions induced statistically significant decreases in the viability of the PRUCC after 1 h of incubation.

CONCLUSIONS

Experimental tests evaluating the cytotoxicity of local anesthetics may prove to be an objective measure of the accessibility of these substances to cells and their anesthetic action.

Chlorhexidine in urethral gel: Does it cause pain at flexible cystoscopy?

OBJECTIVES

To investigate the effect of chlorhexidine gluconate in urethral local anesthetic gel on patients undergoing outpatient flexible cystoscopy. We postulated that chlorhexidine was contributing to the pain and urgency that occurs during and after cystoscopy.

METHODS

A prospective randomized single-blinded study was conducted. A total of 141 patients undergoing outpatient flexible cystoscopy participated in the study. They were randomized to receive 10 mL of 2% lignocaine gel with 0.05% chlorhexidine gluconate (group 1, n = 72) or 10 mL of 2% lignocaine and aqueous gel mixture (group 2, n = 69). Pain scores were recorded on a numerical visual analog scale from 0 to 10.

RESULTS

The groups were well matched for the purposes of comparison. The mean pain scores were not significantly different between groups 1 and 2 at the insertion of the scope (2.1 versus 2.2, P = 0.7), during cystoscopy (1.8 versus 1.9, P = 0.759), and immediately after cystoscopy (1.4 versus 0.8, P = 0.06). However, a significant difference was found in the mean pain scores between groups 1 and 2 during the first void (1.8 versus 1.0, P = 0.031) and after the first void (2.4 versus 1.2, P = 0.007). A significant increase occurred in the reported levels of urgency after cystoscopy in group 1 (P = 0.018). No difference was found in the level of culture-proven symptomatic infection.

CONCLUSIONS

Chlorhexidine appears to contribute to significant levels of pain and urgency after outpatient flexible cystoscopy.

Novel everting urologic access sheath: decreased axial forces during insertion

BACKGROUND

Advancement of urologic instruments through the genitourinary tract is associated with significant axial forces that likely contribute to patient discomfort, even after injection of a local anesthetic, and may lead to mucosal trauma, postprocedural dysuria and hematuria, and increased susceptibility to infection and strictures. Placing an everting urethral sheath prior to instrumentation may decrease these problems.

MATERIALS AND METHODS

Two 7-cm-long, 5-mm diameter urethral luminal models were created, one with and one without an artificial stricture. We measured the forces generated during advancement of a novel everting access sheath (Cystoglide; Percutaneous Systems, Mountain View, CA) through the models in comparison with a representative cystoscope and a urologic dilator simulating a traditional access sheath.

RESULTS

The mean force generated during advancement of the everting sheath was significantly less than that of both the representative cystoscope (P<0.01) and the traditional access sheath (P<0.01). This held true for the urethral models both with and without an artificial stricture (P<0.01) and with and without lubrication (P<0.01).

CONCLUSIONS

This novel introduction sheath markedly decreased the axial forces applied to an artificial urethral luminal wall. It is possible that the clinical use of this technology will decrease the discomfort and potential complications associated with lower urinary-tract endoscopy.

Der Einsatz von Gleitmitteln in der Urologie

Lubricants are used for catheterization and/or endoscopic maneuvers. "The lubricant" should guarantee sufficient lubrification of the urinary tract, good visualization during endoscopy, and excellent local anesthesia. Additionally, asepsis or reliable control of the local bacterial flora of the urethra should be ensured. Modern lubricants fulfil these recommendations; in addition, they provide therapeutic opportunities for local therapy, for instance, of non-gonococcal urethritis. The latest results show that there are a few lubricants with antimicrobiotic influence on MRSA (methicillin-resistant Staphylococcus aureus), which is of great importance because of the steady increase in MRSA-dependent infections.

Randomized double-blind comparison of lidocaine gel and plain lubricating gel in relieving pain during flexible cystoscopy

PURPOSE

To compare the pain induced by outpatient flexible cystoscopy in men having local lidocaine jelly application or plain lubricant.

PATIENTS AND METHODS

We performed a randomized, double-blind study to compare the anesthetic effect of intraurethral 2% lidocaine gel (N = 45) and plain lubricant (N = 46) in men undergoing outpatient flexible cystoscopy. The age, prostate size, and examination time were similar in the two groups. Before cystoscopy, we filled the urethra with 20 mL of gel, which was held for 15 minutes. A 15.5F flexible cystoscope was then used for examination. A 10-point visual analog pain scale (1 = least to 10 = most painful) and a four-point pain grade (grade 1 = least to grade 4 = most painful) were used to measure the pain perception. The amount of postoperative analgesic used and willingness to adopt the same anesthesia for future cystoscopy were also recorded.

RESULTS

The mean pain scores for the lidocaine and plain gel groups were 2.8 +/- 1.1 and 2.5 +/- 1.1, respectively (P = 0.06), while the pain grades for the lidocaine gel and plain gel groups were 1.6 +/- 0.6 and 1.8 +/- 0.7, respectively (P = 0.19). In both groups, many patients (42.2% in the lidocaine gel group and 37% in the plain lubricant group) felt the external sphincter and prostatic urethra were the most uncomfortable areas during cystoscopy. Postcystoscopic analgesics were requested by 12 of 45 patients in the lidocaine group, but only 6 of 46 of the plain-gel group (P = 0.103). When patients were asked if they would desire general anesthesia for better pain control in future examinations, five of the lidocaine group responded positively, while three of the plain-gel group said they would (P = 0.62). The cost of lidocaine gel is about thrice that of the plain gel.

CONCLUSION

Using plain lubricant is cheaper and faster than applying lidocaine gel. The pain score, pain grade, postcystoscopic analgesic requirement, and anesthetics requested for the next cystoscopy were similar in the two groups. However, a larger investigation will be needed to achieve more significant statistical power.

Patient tolerance during outpatient flexible cystoscopy--a prospective, randomized, double-blind study comparing plain lubrication and lidocaine gel

OBJECTIVE

To compare the tolerance of flexible cystoscopy with topical anesthetic versus simple lubrication when the assigned lubricant is instilled 5 min before the exploration.

MATERIAL AND METHODS

A total of 185 consecutive patients were randomly assigned either to simple lubrication (Group 1) or to lidocaine hydrochloride gel (Group 2). Thirteen patients had some kind of difficulty during exploration (stenosis) that required additional manipulation or electrocoagulation for small relapses and were excluded from the final analysis, leaving 172 patients suitable for inclusion. After the intervention, all patients were surveyed regarding their discomfort and pain levels using a verbal scale and a visual analog scale ranging from zero to 10. A chi2 analysis was performed for comparison of qualitative covariables, and quantitative covariables were compared using Student's t-test.

RESULTS

The 172 patients were evenly distributed between the two groups. Of those in Group 1, 89% noted little or no discomfort, compared to 84% in Group 2. Some pain or intense pain was noted by 10% and 16% in Groups 1 and 2, respectively (p > 0.05). The average value on the visual analog scale was 2.10 and 1.97 in Groups 1 and 2, respectively (p > 0.05).

CONCLUSION

There are no differences in the perception of discomfort and pain by patients when anesthetic lubricant or simple lubrication are used if the waiting time before the exploration is 5 min.

Evaluation of pain caused by urethrocystoscopy in patients with superficial bladder cancer: a perspective of quality of life

AIM

The aim of this study is to evaluate patients' tolerance to pain caused by urethrocystoscopy (UCS) in both diagnosis and the period of follow-up in patients with superficial bladder cancer, and to evaluate these results with respect to quality of life.

PATIENTS AND METHODS

Between March 2003 and October 2004, 66 patients with bladder cancer or hematuria underwent UCS and recorded their overall pain level.

RESULTS

The mean age was 60.4 (range 26-83) years. UCS was done only one time in 22 patients for the diagnosis of etiology of hematuria and was done 4 times in 44 patients every 3 months for bladder cancer follow-up. The mean pain scores on first, second, third, and fourth UCS were 4.3+/-2.2, 4.7+/-2.5, 4.68+/-2.45, and 5.1+/-2.5, respectively. Statistically significant differences were found among mean pain scores of patients on first, third, and forth cystoscopic examinations (p < 0.05). No correlation was found between age and pain scores in this study group (p > 0.05).

CONCLUSION

UCS is a painful surgical procedure and pain tolerance was not observed on repeated UCS. Therefore urologists need to use more effective anesthetic methods to provide better patients' tolerance to pain and quality of life during the endoscopic procedure.

Instillation of anesthetic gel is no longer necessary in the era of flexible cystoscopy: a crossover study

BACKGROUND AND PURPOSE

Whether urethral injection of anesthetic and lubricating gel prior to outpatient flexible cystoscopy is worthwhile with regard to pain tolerance has been investigated only in a parallel randomized study. A crossover study was thus designed for further elucidation.

PATIENTS AND METHODS

Each of 33 male patients underwent three flexible cystoscopic examinations with intraurethral instillation of 11 mL of cold anesthetic gel (group 1), plain lubricating gel (group 2), or no gel (group 3). In every examination, 2% lidocaine gel was applied to the cystoscope. Although the cystoscopy was performed by two urologic surgeons, each patient underwent the three consecutive examinations with the same urologist. All the patients separately recorded pain levels during gel instillation, cystoscope insertion, and intravesical observation on a 100-mm visual analog scale after every cystoscopy.

RESULTS

From the median scores, the degree of pain resulting from gel injection was 77.0% and 98.0% of those for cystoscope insertion and intravesical observation, respectively. For each group stratified by anesthetic method, there was no significant difference in the pain score during either cystoscope insertion or intravesical observation.

CONCLUSION

The pain caused by intraurethral gel instillation is significant compared with that from cystoscope insertion and intravesical observation. Anesthetic gel instillation appears to have no significant advantage over anesthesia-free flexible cystoscopic examinations.

Lignocaine gel: does it cause urethral pain rather than prevent it?

OBJECTIVES

To test the hypothesis that the chemical content of lignocaine gel is the cause of urethral pain during its instillation into the urethra.

METHODS

A prospective, double blind study was designed to test whether plain aqueous gel caused less delivery discomfort in the male urethra than 2% lignocaine hydrochloride gel (Instillagel). 100 consecutive, consenting male patients attending for flexible cystoscopy were recruited and randomised to receive 11 ml of 2% lignocaine hydrochloride gel or 11 ml of plain aqueous gel. Upon receiving the gel into the urethra, the patient was asked to score any associated discomfort by using a horizontal, 100mm, non-graphical, visual analogue scale. Statistical comparison between the groups was made using the non-parametric Mann-Whitney U-test.

RESULTS

Statistical analysis by Mann-Whitney U-test showed a significant reduction in urethral delivery discomfort in those patients receiving plain gel compared to those receiving 2% lignocaine hydrochloride gel (p=0.039).

CONCLUSIONS

This current study has shown that plain aqueous gel causes significantly less delivery discomfort in the male urethra than 2% lignocaine hydrochloride gel (Instillagel).

Is instillation of anesthetic gel necessary in flexible cystoscopic examination? A prospective randomized study

OBJECTIVES

To determine whether urethral injection of anesthetic and lubricating agent before outpatient flexible cystoscopic examination is worthwhile regarding patient tolerance of pain.

METHODS

A randomized prospective study was conducted. A total of 133 consecutive men scheduled to undergo flexible cystoscopy were randomized to receive 11 mL of 0.2% oxybuprocaine hydrochloride gel (group 1), 11 mL of plain lubricating gel (group 2), or no gel injection (group 3). In every group, 2% lidocaine gel was applied to the fiberscope. Patients recorded the level of pain during gel instillation, scope insertion, and intravesical observation separately on a 100-mm visual analog self-assessment scale.

RESULTS

Pain scores for gel instillation were approximately two thirds those for scope insertion and intravesical observation in groups 1 and 2. No significant difference was noted in the pain score of each group during either scope insertion or intravesical observation.

CONCLUSIONS

Pain during intraurethral gel instillation is significant. Anesthetic gel instillation has no advantage compared with no-gel injection in men when lubricating gel is applied to a flexible fiberscope.

Flexible cystoscopy: is the volume and content of the urethral gel critical?

PURPOSE

To determine whether volume (10 or 20mL) or the presence of 2% lidocaine (lignocaine) in the gel used for urethral lubrication alters the discomfort felt during flexible cystoscopy.

PATIENTS AND METHODS

A randomized double-blind trial was performed in men attending for flexible cystoscopy. Patients were assigned to one of four groups: 10 mL of gel with or without lidocaine and 20 mL with or without lidocaine. Gel was retained for 10 minutes prior to cystoscopy. Pain felt during both the instillation of the gel and the cystoscopy itself was evaluated using a visual analog scale (0-10).

RESULTS

Interim analysis after 147 patients had been recruited revealed a significant difference between the groups in terms of the pain felt on instillation of the gel, leading to an early termination of the trial. There was a significant reduction in pain on cystoscopy in patients receiving 20 mL of gel if this contained lidocaine.

CONCLUSION

The least pain on cystoscopy occurred in patients receiving 20 mL of gel containing lidocaine.

Randomized trial of 10 mL and 20 mL of 2% intraurethral lidocaine gel and placebo in men undergoing flexible cystoscopy

PURPOSE

To determine if 20 mL of 2% intraurethral lidocaine gel is superior to 10 mL of 2% lidocaine or sterile lubricant for flexible cystoscopy in men.

PATIENTS AND METHODS

A randomized, double-blind, placebo-controlled trial was conducted. Sixty men scheduled to undergo diagnostic flexible cystoscopy were randomized to receive either 20 mL of placebo gel (Group I), 10 mL, of 2% lidocaine gel (Group II) or 20 mL of 2% lidocaine gel (Group III). A penile clamp was applied for 15 minutes to ensure consistent indwelling time in all patients. Patients recorded their pain on a 10-cm non-graphical visual analog scale prior to cystoscopy as a baseline, during the procedure, and immediately after the procedure. Patients also recorded their pain and willingness to have the same anesthetic on a 4-point descriptive scale. Heart rate and mean arterial blood pressure (MAP) were recorded at specific intervals throughout the procedure, and increases in mean arterial pressure were considered objective evidence of patient pain.

RESULTS

Pain perception was not statistically different in the groups (Group I 4.65, Group II 3.93, Group III 3.57; P = 0.406). Pain assessment and willingness to have the same anesthetic also did not differ statistically among the groups. Similarly, differences in the increases in MAP were not statistically significant between groups.

CONCLUSION

Instillation of 20 mL or 10 mL of 2% lidocaine gel has no advantage over plain lubricant in providing anesthesia for flexible cystoscopy in men.

To determine whether the temperature of 2% lignocaine gel affects the initial discomfort which may be associated with its instillation into the male urethra

OBJECTIVE

To determine whether the temperature of 2% lignocaine hydrochloride gel affects the initial discomfort during instillation into the male urethra.

PATIENTS AND METHODS

Sixty consenting men were randomized to receive 11 mL of 2% lignocaine hydrochloride gel (Instillagel, Farco-Pharma GmbH, Cologne, Germany) at 4 degrees C, 22 degrees C or 40 degrees C. The three groups were well matched for age and numbers of previous flexible cystoscopies. The gel was instilled by one operator and the patients were then immediately asked to score the pain on instillation using a 100-mm nongraphical visual analogue scale.

RESULTS

Compared with the control group (at 22 degrees C), there was a statistically significant reduction in pain score in the group receiving cold gel (Student's t-test, P<0.05).

CONCLUSION

The cooling of 2% lignocaine gel significantly reduced the initial discomfort associated with its delivery into the male urethra before any form of urethral instrumentation.

Provision of anesthesia with single application of lidocaine 2% gel

PURPOSE

To compare the efficacy of a single application of lidocaine 2% gel with tetracaine 0.5% drops for topical anesthesia in clear corneal cataract surgery.

SETTING

The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

METHODS

A preliminary toxicity study applied lidocaine 2% gel in the conjunctival fornices of rabbit eyes (n = 9). Biomicroscopic examination was performed and then enucleation at sequential intervals after the application. Intentional intracameral injection of lidocaine gel was performed (n = 3), followed by enucleation. Histopathological analysis was performed on all eyes. A randomized clinical trial comparing topical anesthesia in clear corneal cataract surgery was performed in 25 eyes of 25 patients (12 eyes randomly assigned to lidocaine gel, 13 eyes to tetracaine drops). Corneal sensation was measured with the Cochet-Bonnet aesthesiometer before application of the topical anesthesia, 5 minutes after application, and at the conclusion of surgery. Additional intraoperative local anesthesia and systemic sedation were recorded. Patients' subjective level of comfort was reported 20 minutes after surgery, and the surgeon's perception of patients' comfort was also noted.

RESULTS

In rabbits, lidocaine gel did not cause clinical or histopathological alteration of the ocular tissues. In the clinical study, median corneal sensitivity before application, after 5 minutes, and postoperatively was 6, 0, 0 (maximum sensitivity = 6), respectively, in the lidocaine gel group and 5, 0, 0, respectively, in the tetracaine drops group. Additional local anesthesia was administered in 17% and 31% of patients, respectively. Satisfactory comfort was reported by 58% in the lidocaine gel group and 62% in the tetracaine drops group.

CONCLUSIONS

A single application of lidocaine 2% gel was a safe and effective alternative to multiple topical anesthetic drops for clear corneal cataract surgery. Lidocaine 2% gel was similar to tetracaine drops in provision of corneal anesthesia and patient comfort, while causing no significant toxicity to the ocular surface.