Bacteriological safety and cost-effectiveness of a nonrefluxing valve in the irrigation system during outpatient flexible cystoscopy

Evaluating the Safety of Performing Flexible Cystoscopy When Urinalysis Suggests Presence of "Infection": Results of a Prospective Clinical Study in 2350 patients

Background

There is significant underutilisation of allocated health service resources when a scheduled flexible cystoscopy (FC) is cancelled because a pre-cystoscopy urinalysis (PCU) suggests “infection”, despite patients being asymptomatic for urinary tract infection (UTI).

Objective

To evaluate the risk of UTI or urinary sepsis when FC is performed in asymptomatic patients with a PCU positive for leucocyte esterase and/or nitrites.

Design, setting, and participants

A prospective cohort study was conducted in a high-volume UK centre recruiting all patients undergoing outpatient FC.

Intervention

A protocol was developed to guide response to PCU performed prior to FC, which was performed regardless of the result, unless patients were symptomatic for UTI. All patients completed a questionnaire to identify risk factors and were followed up via a telephone survey and a review of electronic clinical records.

Outcome measurements and statistical analysis

Post-FC UTI was defined as hospital admission with UTI/urinary sepsis or if patients were symptomatic for UTI with receipt of antibiotics or with positive urine culture and sensitivity. An analysis of the association was performed.

Results and limitations

An initial pilot study confirmed the safety and feasibility of our protocol. Of 1996 patients, 136 (6.8%) developed a UTI by our definition, with 51 (2.6%) having a culture-proven infection. The risk was higher in patients with a positive PCU (odds ratio [OR] 1.61, 95% confidence interval [CI] = 1.07–2.40, p = 0.02), history of UTI (OR 1.72, 95% CI = 1.09–2.73, p = 0.02), or a bladder tumour on FC (OR 2.22, 95% CI = 1.27–3.90, p = 0.005). No patient with a positive PCU developed urinary sepsis. The main limitation of this study was the lack of pre-protocol control.

Conclusions

We observed a clinically low and acceptable risk of UTI, with no incidence of sepsis, when FC was performed in asymptomatic patients with a PCU suggesting “infection”. Routine cancellation of these patients is unnecessary and may worsen the burden on health service resources.

Patient summary

We evaluated the safety of performing flexible cystoscopy when the urine dipstick on the day suggested presence of an “infection” but the patient had no symptoms of urinary tract infection (UTI). Our study in over 2000 patients demonstrated a low incidence of UTI, and none of these patients developed sepsis. We therefore recommend that flexible cystoscopy should not be cancelled automatically on the basis of the dipstick result alone, as it might delay a time-sensitive crucial diagnosis.

Low incidence of bacteriuria with outpatient flexible cystoscopy

AIM

To evaluate the incidence of bacteriuria after outpatient diagnostic flexible cystoscopy utilising sterile catheter urine collection technique in women.

MATERIALS AND METHODS

This is a prospective observational study on 78 women who had outpatient flexible cystoscopy for various indications between March and December 2011. Urine for culture was collected by transurethral catheterisation three to five days before cystoscopy, and a second urine sample was collected five to seven days after the procedure. Antibiotic prophylaxis was not administered. Significant bacteriuria was defined as 10(2)  cfu/mL or more of a single organism cultured.

RESULTS

Five (6.4%) had significant bacteriuria and were asymptomatic. The most common organism cultured was Escherichia coli in 4 (80%) of the infected women. No other cystoscopic complication was observed. The mean age was 54.7 years (range 27-80), mean parity was 2.8 (range 0-7). In the study group, 54 (69.2%) women were postmenopausal, 9 (11.5%) had diabetes mellitus, 42 (53.8%) had pelvic organ prolapse and 22 (28.2%) had a prior hysterectomy. Most common indications for cystoscopy were hematuria and recurrent UTI, 48 (61.5%) and 22 (28.2%) women respectively. The cystoscopic findings were normal in 59 (75.6%) women. The procedure was completed within five minutes in all participants.

CONCLUSION

The incidence of bacteriuria following outpatient flexible cystoscopy is low.

The community-based morbidity of flexible cystoscopy

OBJECTIVE

To evaluate patients' experience after flexible cystoscopy (FC), particularly concentrating on the prevalence and degree of symptoms, the frequency of visits to their General Practitioner (GP), subsequent antibiotic rates and the actual incidence of urinary tract infection (UTI).

PATIENTS AND METHODS

Consecutive patients (420) presenting for FC were audited prospectively. A pain score for the procedure was recorded immediately afterward (linear scale 0-10) and a self-administered questionnaire completed at 7 days, to assess the objective and subjective symptoms and their duration, and the incidence of GP visits and subsequent antibiotic provision noted. An interim analysis was conducted on the initial 274 datasets received. To estimate the incidence of FC-induced UTI, the final 110 patients were asked not to consult their GP but to present to the urology department at 3 days after FC (or the emergency department if clinically necessary). These patients had initially provided a mid-stream urine (MSU) sample before FC and were assessed symptomatically with a subsequent sample obtained if a urinary dipstick test 3-days after FC was abnormal.

RESULTS

In all, 384 (91%) evaluable forms were returned. The median (range) pain score for FC was 1.1 (0-8.5), with seven patients (1.8%) recording a pain score of > 5 (all men); 382 patients (99.5%) declared they would be happy to undergo an identical procedure in the future if medically indicated. Pain on voiding was reported in 190 patients (50%), urinary frequency in 142 (37%) and gross haematuria in 73 (19%). Eighteen of the initial 274 patients (6.6%) visited their GP, with 15 (5.5%) of these receiving antibiotics. The MSU data from the final 110 patients showed a FC-mediated infection in three (2.7%).

CONCLUSION

Although FC is well tolerated, gross haematuria, urinary frequency and dysuria occur afterward much more frequently than expected. Patients should be thoroughly counselled before FC about these potential symptoms, to reduce their concern, any unnecessary GP visits and the use of antibiotics.