Alternatives to Cystoscopy

Stu2630 · #1 01-04-2009, 10:27 AM

I was in hospital just before Christmas with a suspected kidney stone. I had severe pain in my right flank and blood in my urine. I was given an ultrasound of my kidney area two days later, but that showed nothing and, by that time, the pain had moved to my lower abdomen (and had become far less severe). Further tests showed there was still blood in my urine so, just before New Year, I was sent for a CT scan as an out-patient.

The Urology Department got my CT result last week but refused to tell me what it showed on the phone. Instead, they sent me an appointment for a "flexible cystoscopy". I phoned to say i had no intention of having such a procedure unless it could be shown to be a matter of life or death and cancelled the appointment. Instead, they have sent me a later appointment to have a "discussion" with the urologist.

Does anyone here know what, if any, alternatives there are to cystoscopy? My daughter (a doctor) has heard of "non-invasive virtual cystoscopy", but I can't find out what it entails or whether it offers a practical alternative to the traditional kind.

Thanks

Stu

Sanslines · #2 01-04-2009, 10:30 AM

Quote:

Originally Posted by Stu2630

I was in hospital just before Christmas with a suspected kidney stone. I had severe pain in my right flank and blood in my urine. I was given an ultrasound of my kidney area two days later, but that showed nothing and, by that time, the pain had moved to my lower abdomen (and had become far less severe). Further tests showed there was still blood in my urine so, just before New Year, I was sent for a CT scan as an out-patient.

The Urology Department got my CT result last week but refused to tell me what it showed on the phone. Instead, they sent me an appointment for a "flexible cystoscopy". I phoned to say i had no intention of having such a procedure unless it could be shown to be a matter of life or death and cancelled the appointment. Instead, they have sent me a later appointment to have a "discussion" with the urologist.

Does anyone here know what, if any, alternatives there are to cystoscopy? My daughter (a doctor) has heard of "non-invasive virtual cystoscopy", but I can't find out what it entails or whether it offers a practical alternative to the traditional kind.

Thanks

Stu

Stu,

What are your reasons for objecting to a cystoscopy procedure? Cystoscopy is the best way to examine the insides of the urethra, bladder, and to a certain extent the prostate. This procedure is commonly used when there is evidence of blood in urine.

Stu2630 · #3 01-04-2009, 10:40 AM

Sans

As you know, I can't contemplate people seeing me partially naked or touching my private parts.

A appreciate what you say about the benefits of cystoscopy, but I'm guessing that there must be others who, perhaps for cultural or religious reasons, would be unwilling to have such a procedure. So there must be an alternative, even if it's not as beneficial.

Stu

Sanslines · #4 01-04-2009, 10:55 AM

Quote:

Originally Posted by Stu2630

Sans

As you know, I can't contemplate people seeing me partially naked or touching my private parts.

A appreciate what you say about the benefits of cystoscopy, but I'm guessing that there must be others who, perhaps for cultural or religious reasons, would be unwilling to have such a procedure. So there must be an alternative, even if it's not as beneficial.

Stu

Stu,

I understand your reasons but from a medical point of view, a cystoscopy procedure is mildly painful as it is done with local anasthesia. I believe that your doctor is recommending this procedure to examine the inside of your urethra for possible ulcers, or other reasons ( I don't want to scare you) concerning the lining of the urethra. A cystoscopy is also used in conjunction with an ultrasound of the bladder (and prostrate) to determine if there might be problems. There really is no better way to look inside of a person than a cystoscopy. It is basically a flexible tube with a light on the end of it so that they can examine the inside of the urethra, bladder, and if there is a restriction of the urethra due to enlarged prostrate. Ultrasound, CT scan, etc certainly have their purposes but do not allow a clear view of the inside of the urethra and bladder. The images from those methods can be rather inconclusive and hence why the cystoscopy is being recommended.

Concerning a related topic, a colonoscopy is often recommended for the purpose of examining the colon for cancer and polyps. In the past, before such a procedure was availible, numerous people developed colon cancer that was not detected in time for life saving treatment.

I understand your hesitation for such procedures, but it is best that you have a closed door talk with your urologist asap to discuss your apprehensions as well as whether your urologist would be comfortable with the results of alternate procedures that may not be definitive enough for your 'blood in urine' condition.

Since you mentioned 'blood in your urine' perhaps this information may be helpful:

In medicine, hematuria (or "haematuria") is the presence of red blood cells (erythrocytes) in the urine. It can be a sign that there is a kidney stone or a tumor in the ureter, urinary bladder, prostate, or urethra. kidneys and the urinary tract, ranging from trivial to lethal. If white blood cells are found in addition to red blood cells, then it is a signal of urinary tract infection.

Types

Red discolouration of the urine can have various causes:

Red blood cells
- Microscopic hematuria (small amounts of blood, can be seen only on urinalysis or light microscopy)
- Macroscopic hematuria (or "frank" or "gross") hematuria
Hemoglobin (only the red pigment, not the red blood cells)
Other pigments
- Porphyrins in porphyria
- Betanin, after eating beets

Analysis

A patient will be asked a number of questions:

Have you passed any blood clots?
Has a kidney stone been passed (noise in toilet bowl)?
Is the red colour mixed in completely, or does the colour change during an episode of urination?
Does it occur only after getting up?
Have you recently had a sore throat?

Diagnosis

Often, the diagnosis is made on the basis of the medical history and some blood tests—especially in young people in whom the risk of malignancy is negligible and the symptoms are generally self-limited.
Ultrasound investigation of the renal tract is often used to distinguish between various sources of bleeding. X-rays can be used to identify kidney stones, although CT scanning is more precise.
In older patients, cystoscopy with biopsy of suspected lesions is often employed to investigate for bladder cancer.

Causes

Common causes of macroscopic hematuria/ haematuria (i.e. blood visible in the urine) include:

Benign familial hematuria
Urinary Schistosomiasis (caused by Schistosoma haematobium) - a major cause for hematuria in many African and Middle-Eastern countries;
IgA nephropathy ("Berger's disease") - occurs during viral infections in predisposed patients;
Kidney stones (or bladder stones);
Bladder cancer;
Renal cell carcinoma - occasionally presents with bleeding;
Paroxysmal nocturnal hemoglobinuria - a rare disease where hemoglobin of hemolysed cells is passed into the urine.
Urinary tract infection with some bacterial species including strains of EPEC and Staphylococcus saprophyticus
Sickle cell trait can precipitate large amounts of red blood cell discharge, but only a small number of individuals endure this problem
Arteriovenous malformation of the kidney (rare, but may impress like renal cell carcinoma on scans as both are highly vascular)
Nephritic syndrome (a condition associated with post-streptococcal and rapidly progressing glomerulonephritis).
Fibrinoid necrosis of the Glomeruli ( as a result of malignant hypertension)
Ureteral Pelvic Junction Obstruction (UPJ) is a rare condition beginning from birth in which the ureter is blocked between the kidney and bladder. This condition may cause blood in the urine.

http://en.wikipedia.org/wiki/Hematuria

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Cystoscopy:

Endoscopy of the urinary bladder via the urethra is called cystoscopy. Diagnostic cystoscopy is usually carried out with local anaesthesia. General anaesthesia is sometimes used for operative cystoscopic procedures.

When a patient has a urinary problem, the doctor may use a cystoscope to see the inside of the bladder and urethra.

The urethra is the tube that carries urine from the bladder to the outside of the body. The cystoscope has lenses like a telescope or microscope. These lenses let the doctor focus on the inner surfaces of the urinary tract. Some cystoscopes use optical fibres (flexible glass fibres) that carry an image from the tip of the instrument to a viewing piece at the other end. The cystoscope is as thick as a pencil and has a light at the tip. Many cystoscopes have extra tubes to guide other instruments for surgical procedures to treat urinary problems.

There are two main types of cystoscopy - flexible and rigid - differing in the flexibility of the cystoscope. Flexible cystoscopy is carried out using local anaesthesia on both sexes. Typically, lidocaine gel (such as the brand name Instillagel) is used as an anaesthetic, instilled in the urethra. Rigid cystoscopy can be performed under the same conditions, but is generally carried out under general anaesthesia, particularly in male subjects, due to the pain caused by the probe.

A doctor may recommend cystoscopy for any of the following conditions:^[1]

Interstitial Cystitis
Frequent urinary tract infections
Blood in the urine (hematuria)
Loss of bladder control (incontinence) or overactive bladder
Unusual cells found in urine sample
Need for a bladder catheter
Painful urination, chronic pelvic pain, or interstitial cystitis
Urinary blockage such as from prostate enlargement, stricture, or narrowing of the urinary tract
Stone in the urinary tract
Unusual growth, polyp, tumor, or cancer

Male and female urinary tracts

Images from a cystoscopy. The top two images show the interior of the bladder of a male patient. In the top-right image, the cystoscope has been bent within the bladder to look back on itself. The bottom two images show an inflamed urethra

If a patient has a stone lodged higher in the urinary tract, the doctor may use a much finer calibre scope called a ureteroscope through the bladder and up into the ureter. (The ureter is the tube that carries urine from the kidney to the bladder). The doctor can then see the stone and remove it with a small basket at the end of a wire which is inserted through an extra tube in the ureteroscope. For larger stones, the doctor may also use the extra tube in the ureteroscope to extend a flexible fiber that carries a laser beam to break the stone into smaller pieces that can then pass out of the body in the urine.

Test Procedures

Doctors may have special instructions, but in most cases, patients are able to eat normally and return to normal activities after the test. Patients are sometimes asked to give a urine sample before the test to check for infection. These patients should avoid urinating for an hour before this part of the test.

Patients will have to remove their clothing covering the lower part of the body, although some doctors may prefer if the patient wears a hospital gown for the examination and covers the lower part of the body with a sterile drape. In most cases, patients lie on their backs with their knees slightly parted. Occasionally, a patient may also need to have their knees raised. A doctor, nurse or technician will clean the area around the urethral opening and apply a local anesthetic.

Patients receiving a ureteroscopy may receive a spinal or general anaesthetic.
The doctor will gently insert the tip of the cystoscope into the urethra and slowly glide it up into the bladder. The procedure is more painful for men than for women due to the length of the urethra. Relaxing the pelvic muscles helps make this part of the test easier. A sterile liquid (water, saline, or glycine solution) will flow through the cystoscope to slowly fill the bladder and stretch it so that the doctor has a better view of the bladder wall.
As the bladder reaches capacity, patients typically feel some mild discomfort and the urge to urinate.

The time from insertion of the cystoscope to removal may be only a few minutes, or it may be longer if the doctor finds a stone and decides to remove it. Taking a biopsy (a small tissue sample for examination under a microscope) will also make the procedure last longer. In most cases, the entire examination, including preparation, will take about 15 to 20 minutes.

After the test, patients often have some burning feeling when they urinate and often see small amounts of blood in their urine. Occasionally, patients may feel some lower abdominal pains, reflecting bladder muscle spasms, but these are not common.

Common prescriptions to relieve discomfort after the test include:

Drinking 32 fluid ounces (1 L) of water over 2 hours.
Taking a warm bath to relieve the burning feeling.
Holding a warm, damp washcloth over the urethral opening.

Some doctors will prescribe an antibiotic to take for 1 or 2 days to prevent an infection. However, recent trends have been to discourage this kind of prophylactic treatment (prescribing antibiotics as a preventative when there is no other evidence of infection) because it tends to increase the rate at which bacteria develop resistance to the antibiotic drug.

http://en.wikipedia.org/wiki/Cystoscopy

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I assume that your urine has already been checked under a microscope for bacteria as this is a standard and initial test.

walter05 · #5 01-04-2009, 10:59 AM

http://www.webmd.com/a-to-z-guides/cystoscopy-16692 is a link for information.

http://www.webmd.com/prostate-cancer/guide/cystoscopy is another link.

http://www.kidney.niddk.nih.gov/kudi...bs/cystoscopy/ is a link that describes the procedure.

Your life, health, and/or quality of life may depend on it. For someone without your hangups about nudity, this is an invasive, potentially embarrassing, and potentially uncomfortable procedure.

However, if there may be stones in your bladder or prostate, a possibility of cancer, etc. the cystoscope is the best way for your doctor to find out.

I would tell your doctor the truth. Tell him or her how embarrassed you are. The doctor should help you through it.

Please, I beg of you. You are worth it. Don't wait.

If you don't think you are worth it, think about your wife and daughter. They need you.

Fitz1980 · #6 01-04-2009, 10:59 AM

Quote:

Originally Posted by Stu2630

Sans

As you know, I can't contemplate people seeing me partially naked or touching my private parts.

A appreciate what you say about the benefits of cystoscopy, but I'm guessing that there must be others who, perhaps for cultural or religious reasons, would be unwilling to have such a procedure. So there must be an alternative, even if it's not as beneficial.

Stu

If it wasn't for the fact that you have been here for so long I'd have to ask if you were serious. I still kind of wonder...

But as far as the rest goes, I'm going to go with Dr Perry Cox (a fictional character from the show 'Scrubs')

Patient:
I'm a Jehova's Witness, I can't get a transfusion. We believe that blood should not be passed from person to person

Dr. Cox:
Well I'm a doctor and we believe that without surgery a patient in your condition can suffer from a major case of deadness.

Carla:
Don't worry, he will figure out another way to treat you

Dr. Cox:
[laughing as he walks off]
Hehehe! No he won't!

Later on in the ep Carla confronts him and points out that he had previously jumped through a bunch of hoops to help a patient who was allergic to the standard treatment for some ailment. He pointed out that the allergic patient didn't choose to be allergic to whatever medication while the religious one is choosing to place irrational beliefs above basic science and medical treatment.

So my answer to you is that you are choosing to be difficult for no other reason than your irrational hangups. If you have a medical problem than you should DO WHAT YOUR DOCTOR (and indeed all reputable doctors) RECOMMEND YOU DO. If you do not than you have only yourself to blame for the consequences.

Sorry for flying off the handle. But my Mom is a nurse so I know that medical professionals bust their butts daily trying to save people and even when they do everything that they could nature, luck or God doesn't always cooperate and people die so I get frustrated when patients CHOOSE to make things harder for no rational reason and expect to be accommodated.

BTW this is all assuming that Stu is serious here. I still don't know if he's a troll or sock puppet. I've seen dedicated loons who posted crazy untrue stuff daily to boards just to get a rise out of people, but never any who's posts were so long an well thought out.

walter05 · #7 01-04-2009, 11:03 AM

I found this after my post. http://prostatitis.org/cystoscopy.html

I think this may help you.

Walter

Sanslines · #8 01-04-2009, 11:05 AM

Stu,

This is what virtual cystoscopy is all about:

UroToday.com - Bladder cancer is one of the common urological malignancies, with the need for life-long follow-up. It represents 4.5% of new cancer diagnoses. The gold-standard of current diagnosis, as well as follow-up involves direct visualisation of the bladder mucosa with the use of a flexible/rigid cystoscopy.

There are however, problems with instrumentation of the urinary tract for visualisation, including urethral trauma, which may cause late stricture, as well as infection, and failure to visualise the mucosa due to debris or blood. Contraindications include acute cystitis, prostatitis, urethritis, occlusive prostatic enlargement, and urethral stricture.

CT virtual cystography (VC) has emerged as a potentially viable alternative to current invasive methods of bladder visualisation. Using 3D technology, the technique was first proposed by Vining and co-workers in North Carolina (USA), and either involves:

1). Passing a urinary catheter, and using double contrast with CO2 and radio-opaque dye, or:
2). Using IV contrast, with no need to instrument the urinary tract.

VC can be performed using either CT or MRI, though the latter is time-consuming, expensive, and labour intensive (though slightly more sensitive and specific). Sensitivity and specificity of CT VC has been reported in a number of papers since 1995 to be as high as 95% and 87% respectively for identifying bladder tumours, and 95% and 93% respectively for identifying abnormal bladder mucosa due to all causes.

Problems include the size of visible lesions, being poor for small (<4mm), and flat lesions such as carcinoma in-situ. Another disadvantage is that the urologist is unable to manage any lesion found immediately, for example by fulguration, and cannot provide tissue diagnosis. It will place an extra burden on already busy CT scanners, and will require specialist review of images.

Whilst it is recognised that the limitations of CT virtual cystoscopy currently prevent its mainstream clinical use, it is hoped that in the future, with advances in technology, the technique may be of practicable use.

Written by: Michael Kipling, MRCS, Aza Mohammed, MRCS, as part of Beyond the Abstract on Urotoday.com

UroToday - the only urology website with original content written by global urology key opinion leaders actively engaged in clinical practice.

To access the latest urology news releases from UroToday, go to: www.urotoday.com

http://www.medicalnewstoday.com/articles/120407.php

The bottom line with all of this information is that it will be up to your urologist to decide what are the best tests for you based upon the specific information that he has.

My experience with some of these modern digital methods can be summed up with a comparison of traditional dental xrays to the more modern digital images. There still is a great deal of controversy in the dental community concerning the advantages and disadvantages of one method over another. Digital techiques can be advantageous over traditional to the extent that the software that controls and generates the 3-d images is sufficienly developed and refined. Such refinements occur on a continuous basis. A parallel can certainly be drawn between traditional medical procedures versus 3-D computer geenrated non invasive procedures and this also include cystoscopy.

walter05 · #9 01-04-2009, 11:09 AM

As I have looked over the information, I have seen enough posts from men such as this:

Ed:
in my case, cystoscopy turned out to be of the utmost importance and benefit as it disclosed a malignant polyp in my bladder which had simulated very well the symptoms of BPH and/or prostatitis. There was no blood in my urine which is a classic indicator of bladder cancer. According to my urologist, the urine test for cancer was negative prior to the cystoscopy. So, I cast a definite vote for having it done. It is not comfortable but not as bad as you think it will be. Good luck!

I have also seen some that indicated that the procedure was a failure if the prostate was too large.

I know this will not sound better to you. But, you may want your doctor to try a digital rectal exam first. Palpitation of the prostate to see if it is enlarged may help indicate how painful the procedure will be or not.

Stu2630 · #10 01-04-2009, 11:22 AM

Sans

Quote:

it is best that you have a closed door talk with your urologist asap to discuss your apprehensions as well as whether your urologist would be comfortable with the results of alternate procedures that may not be difinitive enough for your 'blood in urine' condition.

Yup, that's what my eldest daughter recommended and it's pretty much what I had in mind. As I said, if this were a life-or-death decision then I'd bite the bullet, but I believe it is more a matter of routine, i.e. that if they have a patient with unexplained haematuria, they get a cystoscopy. I'm not playing that game. And I want to know what, if any, alternatives there are.

Thanks for all the information about it!

Walter

I appreciate your thoughts. As I explained to Sanslines, I would find a cystoscopy traumatic and I'm not prepared to go through that "just to be on the safe side" because that's what they like to do for people with a microscopic amount of blood in their urine.

Thanks for the prostatitis link - I'll read that.

Fitz

Thanks for your input, too.

Medical professionals at this side of the pond are sometimes blase about people's sensitivities and sensibilities and personal dignity is often utterly disregarded. Of course I don't want to die, but sometimes we have to make a calculated decision of risks versus benefits.

What I was hoping for here was someone with a medical background or other knowledge of this area to explain the possible alternatives to this highly unpleasant, invasive procedure, so that I would be able to discuss it with the urologist from a position of knowledge. I Googled it but have found very little.

Stu