FEMALE CYSTOSCOPY: Guidelines and Technique
SHARAD D BAPAT
Cystoscopy is an important diagnostic investigation which gives valuable information. It has several therapeutic applications as well. The basic principles and indications for cystoscopy examination are similar in males and females. However, there are important differences due to the length of urethra. In this presentation, I shall restrict myself to the technique of Cystoscopy.
Female urethra being much shorter, requires a special cystoscope sheath with a short bevel for doing urethroscopy. If such a sheath is not available, a special adaptor (Fig. 1) is required to prevent irrigating fluid from leaking out. It is also necessary to introduce the scope carefully under vision as the standard cystoscope is too long for the length of the urethra and if a cystoscope is introduced blindly, in an empty bladder, there could be a risk of bladder perforation. Another problem of a short urethra, is that the cystoscope may have to be supported by an assistant during cystoscopic manipulation. The long length of the male urethra gives a natural advantage as there is less tendency for the instrument to fall out.
Fig. 1: Nickell cystoscope adaptor for female urethroscope.
It is preferable to do female cystoscopy under general anaesthesia as the lithotomy position required for cystoscopy and cystoscopic procedures, is often embarrassing for a female of any age, especially in a country like India. However, at times it is necessary to know the functional bladder capacity before anaesthesia.
Following points should be noted during female cystoscopy - Meatal calibre - This is calibrated by bougie la bole (Fig. 2). The meatus of a normal adult female is 24 ch in size. If the meatus is narrow, it is best to cut this to a size, generally 3 or 6 ch size larger than the expected normal. Thus, if an adult or menopausal woman has a meatal calibration of 18, meatotomy could be done to size 29 to 33. Urethrotomy is a better procedure than doing urethral dilatation as during dilatation the urethra splits irregularly at different places resulting in bleeding a later scarring. Hence, it is best to do urethrotomy at 3 and 9 O’clock positions. Subsequent urethral dilatation will result in urethra splitting at these two places only.
Fig. 2: Bougie la bole for weethral calibration.
The best instrument for doing female urethrotomy is Hertel’s urethrotome (Fig. 3). After urethrotomy, the urethra could be dilated using Hegars dilators.
Fig. 3: Hertel urethrotome for female urethrotomy.
During cystoscopy, the irrigating height should be kept as low as possible (30 to 40 cms only).
Before starting Cystoscopy
1.A sample of urine is collected for culture using a 7 ch sterile infant feeding tube followed by measurement of residual urine. A mid stream sample of urine in elderly women is invariably contaminated due to contact with labial skin or vaginal secretions.
2.Meatal calibration is done with bougie la bole.
Cystoscopy should begin with filling the bladder at a low pressure (30 to 40 cms of water) and the bladder capacity is noted once the fluid stops entering the bladder.
The entire bladder is then examined sector wise from 7 to 12 O’clock position and from 5 to 1 O’clock position. Each sector must include the entire length of urinary bladder. Any abnormalities such as vesical calculi, granulations, foreign bodies, diverticulae, trabeculae, saccules, cellules, neoplasms etc are carefully noted. Once the bladder is inspected with a short beaked (short bevel) cystoscope sheath, additional examination could be carried out using a larger sheath with a longer bevel so as to accommodate larger instruments, ureteric catheters of different sizes including chevassue bulb ureteric catheters, grasping forceps, biopsy forceps etc. If a bladder accommodates only a small quantity of fluid, the irrigating height could be increased to 50, 60 and 80 cms. The bladder should be inspected with both 30 and 70 degree angle telescopes. However, with modern 30 degree wide angle telescope, it is possible to visualize all parts of the urinary bladder.
As the cystoscope is being withdrawn, trigone and bladder neck is carefully inspected for any abnormalities such as squamous metaplasia, polyps etc.
A vaginoscopy is carried out at the end, so as to inspect all parts of vagina. It is helpful to have a head low position for doing vaginoscopy.
At the end of the procedure, a catheter may have to be kept. Alternately, if catheter is not considered necessary, a sterile pad is applied over the vagina so as to avoid any soiling/blood staining of underclothes. If there is a large diverticulum, this will need a thorough inspection followed by irrigation of the bladder with 0.5 to 1.0% povidon iodine solution.
If major abnormalities like stone, tumour, endometriosis etc are noted, additional equipment for performing biopsy, fulguration, lithotripsy or bladder neck resection etc would be necessary.
When doing cystoscopy for chyluria, it is necessary to do the procedure without anaesthesia or under local anaesthesia. Chyle appears only after food or heavy meal and if a patient is called on empty stomach, chylous efflux will be easily missed.
For haematuria, it is best to do cystoscopy during the episode of bleeding as this will enable the urologist to establish the source as well as the kidney from which the blood is coming.
At the end of every cystoscopy, a record of all the cystoscopy findings should be made immediately, in a printed format. It is far too easy to forget some details if a second cystoscopy is done after the first.
I have followed the above technique for several years and find this extremely useful and informative.