Urethrocystoscopic Examination In Female
Indications of Cystourethroscopy
Cystourethroscopy techniques and anesthesia
I- Diagnostic and dynamic urethroscopy
II- Diagnostic cystoscopy
Urethrocystoscopic findings in incontinent women and pelvic changes
Since the beginning of twenty century, endoscopy has evolved as the definitive procedure for the evaluation of LUT. The value of endoscopy is greatly increased when the findings are integrated with radiologic and urodynamic examinations. Cystoscopic evaluation of the female urinary tract can be provide information on many aspects of the dynamics of voiding, as well as allow the physician to visualize mucosal and structural abnormalities directly. Incompetence of the BN, as well as the extent of prolapse of the proximal urethra and base of the bladder, can be determined endoscopically. Stress incontinence with a component of DI or incontinence due to instability alone can be assessed by determining patient's ability to suppress voluntary detrusor contractions (O'Donnell, 1983).
Dynamic urethroscopy offered a simple office procedure that considerably improved the diagnostic evaluation of the LUT (Robertson, 1973). Dynamic nature of the technique also provides a method of evaluation of the functional integrity of urethral sphincteric mechanism during bladder filling and with superimposition of varying commands and stressful situations. When coordinated with urodynamic techniques (measuring urethral opening pressure-UOP and intravesical pressure by gas or fluid manometer), it completes the essential composite evaluation of normal and abnormal urethrovesical function (Robertson, 1985).
Indications of Urethrocystoscopy
1- Diagnostic indications include hematuria, irritative voiding symptoms, urinary incontinence, urethral diverticulum and urogenital fistulas. Endoscopy is useful in diagnosis of post renal conditions, including neoplasms of the bladder and urethra, urethral polyps, chronic cystitis, recurrent cystitis, interstitial cystitis, urolithiasis, foreign bodies, DI, sensory urgency, partial urinary retention, moderate to severe POP and for patients who do not respond to initial therapy. Cystourethroscopy also has a role in the diagnosis of ISD (Cundiff and Bent, 1999).
2- Operative indications: Urethrocystoscopy is commonly used to perform and judge coaptation during periurethral injections, assess elevation of UVJ during needle urethropexy and suburethral sling procedures, facilitate surgical repair of urinary tract fistula and urethral diverticulum, ensure safe placement of suprapubic catheters and evaluate the ureters and bladder mucosa for inadvertent damage during surgery (Cundiff and Bent, 1999).
A convenient approach begins with urethroscopy followed by cystoscopy. Endoscopy should be avoided in the presence of any active UTI (Cundiff and Bent, 1999).
Endoscopic evaluation of the urethra and bladder should be done without discomfort to the patient, while allowing the physician to make a complete and thorough evaluation (O'Donnell, 1983).
A-Conscious sedation: Midazolam (Dormicum) is well known and established in endoscopic procedures for so-called conscious sedation. It is short acting sleep-inducing agent. The initial dose is 2.5mg/ 5-10 min slowly intravenous before beginning of cystoscopy. Further doses of 1mg may be given as necessary. In cases of advanced age, initial dose must be reduced to 1-1.5mg (Cordruwisch et al, 2000).
B- Topical anesthetics: Topical anesthetics are typically avoided during urethroscopy because they can affect the color of the urethral mucosa (Cundiff and Bent, 1996).
C- Effects of spinal anesthesia on bladder neck position: During spinal anesthesia, the BN was found to be located significantly lower and more posterior and clinical stress test was positive in parous continent women and not in continent nulliparous. These data provide additional evidence for the importance of neuromuscular function in the etiology of pelvic floor dysfunction and genuine SUI (Hanzal et al, 1995). Epidural anesthesia paralyzes the voluntary pelvic muscle groups (Schuessler et al, 1988).
I- Diagnostic urethroscopy
Urethral meatus is cleansed with a disinfectant, with the distension medium flowing and the urethroscope is advanced into the urethral meatus. The center of the urethral lumen is maintained in the center of the operator’s visual field and the urethral lumen, distended by the infusion medium, is followed to the UVJ. Urethral mucosa is examined for redness, pallor, exudates and polyps as the urethroscope is advanced. The mucosa is normally pink and smooth (Plates 1& 2) and a posterior longitudinal ridge, urethral crest, may be seen (Plate 3). When the UVJ, typically round or horseshoe-shaped is reached flow is stopped and the area is observed for fronds (feathery structures with a central capillary) (Plate 4) and polyps (bulbous structures) (Scotti et al, 1990). Size of the normal adult female urethra is equivalent to the caliber of a No. 20 to 30 French catheter. However, a distal urethral caliber equivalent to a No. 20 French catheter or less is a normal finding in 30% of asymptomatic women (Hole, 1972).
Plate 1 Normal urethra opens to flow
Plate 2 Normal urethral coaptation
Plate 3 Urethral crest
Plate 4 UVJ fronds
Dynamic urethroscopy is performed after the bladder has a volume of 300 ml. The urethroscope is withdrawn until the UVJ closes one third of the way and the response of the UVJ to “hold your urine” and “squeeze your rectum” commands is evaluated (Plate 5). The normal UVJ closes completely or most of the way during the hold maneuvers (Plate 6). The urethroscope is then withdrawn until the UVJ is two thirds closed and its response to Valsalva maneuver is observed and the urethroscope is moved to keep the lumen in the visual field. The normal response is UVJ closure with all of these commands. This provides a subjective evaluation of UVJ mobility as the normal UVJ moves minimally or closes with these commands (Bent and Ostergard, 1989).
Plate 5 UVJ, open
Plate 6 UVJ closed at holding
Mid urethra has the highest resting pressure in the urethra. This is due to striated muscle fibers surrounding middle third of the urethra. In normal women, midurethra has an average pressure of 75cm water. This is the only point in the urethra where the resting pressure exceeds the pressure of the infusion medium (O'Donnell, 1983).
Corpus spongiosum of the female urethra lies between the mucosa and muscularis, beginning approximately 0.5cm distal to the internal urethral orifice and extends over the length of the urethra, becoming less abundant near meatus. This vascular component provides passive resistance to outflow of urine, in addition to serving as a gasket for the sphincter mechanisms. By stating and stopping the flow of infusion medium, the character of the coaptation and separation of the mucosal folds allows clinical assessment of the resilience of the submucosa. The height of the column of infusion medium should be about 50cm water. At this level, the pressure of the infusion medium is greater than the normal resting pressure of the proximal and distal urethra, but less than that of the normal midurethra. With loss of vascular cushion, the other forces of continence will not suffice to produce coaptation of the urethral mucosa for watertight closure (O'Donnell, 1983).
It is not possible to stimulate a vesical contraction without the volitional agreement of the patient. If a vesical contraction does occur, the normal patient always suppresses it. When voiding occurs, the urethra opens to the meatus and water escapes around the sheath (Plate 7); followed by smooth closure when voiding ceases. At the end, the urethroscope is withdrawn while a vaginal finger massages the urethra against the scope. Exudates or diverticular openings may be seen (Robertson, 1985).
Plate 7 UVJ open, normal voiding
II- Diagnostic cystoscopy
Cystoscopy is performed using a 30-or 70-degree rigid telescope with a 19-French-sheath. Cystoscope is placed into urethral meatus with the level directed posteriorly and advanced to bladder under direct vision. Infusion of water is maintained at a slow rate until patient report fullness or a volume of approximately 400ml is reached. Orientation is easily established by identifying an air bubble anteriorly at the dome of the bladder. This serves as a landmark during the remainder of examination. Beginning at superior dome to UVJ, the survey progresses in 12 sweeps, corresponding to points of a clock (figure 1). Trigone and ureteral orifices are visualized by angling the scope downward at a 30 degrees angle and laterally. Visualization of the bladder base can be difficult in patients with a large cystocele unless the prolapse is reduced with a vaginal finger. Mucosa is examined for color, vascularity, trabeculation and abnormal lesions such as plaques or masses. Once the survey is complete, the telescope is removed while the sheath is left in place. This allows the bladder to drain and permit measurement of the volume of drained fluid (Cundiff and Bent, 1996).
Figure 1: Diagnostic cystoscopy. A survey of vesical cavity by making 12 sweeps from the superior bladder to the urethrovesical junction is illustrated. The sweep is demonstrated (Quoted from Cundiff and Bent, 1999).
Normal bladder mucosa has a smooth surface with a pale pink to glistening white hue. Translucent mucosa affords easy visualization of the branched submucosa vasculature. A thickened white membrane with a villous contour commonly covers the reddened granular surface of the trigone. Histological evaluation of the layer reveals squamous metaplasia. There is marked variation in ureteral orifices, but they are generally circular or slit-like openings. Distended bladder is roughly spherical in shape but numerous folds of mucosa are evident in empty or partially filled bladder (Cundiff and Bent, 1999).
As bladder fills, inverted U-shaped UVJ closes. With further bladder filling there is further urethral tightening ahead of the endoscope. This represents increased tone of periurethral striated muscle which develops as bladder fills. Asking the patient to hold urine or to bear down, it causes further tightening of the vesical neck which remains stationary in normal patient (Robertson, 1985).
A- Urethroscopic pathology
In cases of true SUI a law entering pressure is recorded, as vesical neck is poorly supported. When patient bears down, vesical neck opens and drops. When endoscope is threaded back and forth through vesical neck, it tends to funnel and closes sluggishly. Intravesical pressure is normal (ml water). The tip of endoscope is withdrawn to midurethra, and the patient is instructed to bear down. If the urethra opens again, incompetence of both primary and secondary 'sphincters' is demonstrated. Some patients have incompetence of the vesical neck but are continent owing to a competent midurethra. In unstable bladder, sensation of bladder filling is noted early. Vesical neck may not close during bladder filling. Intravesical pressure is high, and fine trabeculations are noted (Robertson, 1983). In some patients bladder filling stimulates detrusor contraction, in others, one of detrusor activating procedures cause vesical contraction and these patients cannot suppress it (Robertson, 1985).
In patients with SUI, resting urethral pressure is low throughout urethra (Tanagho, 1973), and average maximum urethral pressure is 45cm water (O'Donnell, 1983). During stress in patient with GSI, vesical neck behaves like an inelastic rubber band. After three or four vigorous coughs vesical neck opens (funnels) and descends. It is very slow to reform and to return to its position. Similarly, the vesical neck reacts sluggishly, if at all, to the “hold” command (Cundiff and Bent, 1999) (Figure 2).
Figure 2: Evaluating urethral hypermobility using dynamic urethroscopy. A urethroscope is positioned to view the UVJ (window cut away to visualize the UVJ). B, as the patient coughs, the UVJ descends and opens (the urethroscope is elevated to follow the UVJ visualized through cutaway) (Quoted from Cundiff and Bent, 1999).
During dynamic urethroscopy p the “hold” and “squeeze” commands, and the UVJ generally opens and descends in response to Valsalva maneuvers. The patient with ISD may have a rigid, immobile urethra, with the UVJ unresponsive to commands (Cundiff and Bent, 1999). The agency for Health Care Policy and Research coined the term intrinsic sphincteric deficiency, and defined it conceptually as a condition in which 'the urethral sphincter is unable to coapt and generate enough resistance to retain urine in the bladder (UIGP, 1992).
atient with GSI type III (ISD) cannot close the UVJ to
Urethral opening pressure (UOP) is not a urethral closure pressure profile but simply that pressure necessary to open the urethra. The UOP in normal patient registers between 70 and 90 cm H2O. In GSI, UOP is below 70 cm H2O and above 90 cm H2O in DI (Table 1) (Robertson, 1985).
1-Urethral opening pressure.
2-Urethral visualization from external meatus to urethrovesical junction.
3-Trigonal and ureteral orifice visualization.
4-With observation of the urethrovesical junction
A-During bladder filling
B-With hold command
C-With Valsalva and cough
5-Observation of urethra for exudate and abnormal orifices.
A-Posterior urethral glandular exudate
6-Continued urethral observation
A-Occlusion of urethrovesical junction
B- Urethral palpation for expression of exudates
Table 1 The procedure for the clinical evaluation of patients with GSI or other genitourinary problems (Robertson, 1985).
In woman with SUI, when patient is requested to cough with maximum force, mild SUI (type I) will usually be demonstrated by a fleeting moment of opening and closing of BN. Varying degrees of hypermobility of BN will also be seen. In more symptomatic patients (type II), forceful cough will cause BN to appear wide open, and significant UVJ prolapse will occur. As patient relaxes, the proximal urethra and BN will return to the previous position, and the BN will close. Filling of the bladder may produce incompetence of the vesical neck so that the BN is open at rest when the bladder is filled. Downward motion of BN is 2 to 3cm in type I BN prolapse. In type II, downward and backward movement is 3 to 6cm and sometimes more (O'Donnell, 1983).
Careful endoscopic assessment of the periurethral glands is very important, since chronic inflammation of these glands produce a number of voiding symptoms (Aldridge et al, 1978). A stricture is a narrowing of the urethra that typically occurs at the meatus, although proximal or mid-urethral narrowing may also result from prior urethral surgery. Hypoestrogenism results in pale urothelium (Plate 8). A urethral lumen that is pale and rigid and is unresponsive to commands indicates fibrosis and may result in ISD (Plate 9) (Cundiff, 1999).
Plate 8 Pale hypoestrogenic urethra
Plate 9 Fibrotic urethra
In patients with voiding difficulty, may have functional outlet obstruction or poor detrusor contraction. During voluntary voiding, if funneling of the BN is seen to combine with a sustained detrusor contraction, functional distal urethral obstruction is generally present. In patients having poor detrusor function, endoscopy during voluntary voiding will show incomplete funneling of the BN, the BN opens but retains its diaphragm appearance, or in the patient unable to maintain a detrusor contraction to completion of voiding, involuntary closure of the BN occurs, resulting in cessation of voiding (O'Donnell, 1983).
B- Cystoscopy pathology
Pathology affecting bladder can be categorized as mucosal lesions or structural variations (Cundiff and Bent, 1999).
Decreased bladder compliance results in elevated intravesical pressure, submucosal veins, which are readily visible endoscopically, will appear blanched as they cross the muscle fibers because of pressure placed across the vein by hydrostatic pressure in the bladder (O'Donnell, 1983).
Interstitial cystitis (IC) is often associated with hematuria and fibrosis. Pathognomonic lesions appear on refilling the bladder, after initially filling to maximum cystometric capacity. Glomerulations are the primary findings in very mild cases. These petechial hemorrhages are small red dots that may coalesce to form larger hemorrhagic areas. Classic Hunner ulcer is seen in more severe cases of IC (Messing and Stamey, 1978).
Inflammatory polyps are often identified at the UVJ if the cystoscope is retracted into the proximal urethra and the infusion interrupted to allow them to float into the field of view. Cystitis cystica consists of clear mucosal cysts usually found in multiple areas over the bladder base. Single layers of subepithelial transitional cells, which degenerate with central liquefaction, form the cysts. Cystitis glandularis has a similar appearance to cystitis cystica, but the cysts are not clear and have a less uniform contour. As in cystitis glandularis, the mechanism of formation is a glandular metaplasia. Although it is twice as common in men, bladder cancer is the most common genitourinary neoplasm in women. Cystoscopic appearance is variable, depending on histological type and grade, but usually reveals a raised lesion with a villous feathery or papillary appearance (Cundiff and Bent, 1999).
Trabeculations are considerably more common than auxiliary ureteral orifices or ureterocele. They become evident with distension of the bladder to volumes approaching maximum cystometric capacity. They appear as interlaced cords of different diameters with intervening saculations. They represent hypertrophied detrusor musculature associated with DI and functional or anatomic bladder obstruction (Kelalis et al, 1967).
Urethrocystoscopic findings in incontinent women and pelvic changes
1-Genuine stress incontinence (GSI): Poor support of the UVJ presents in GSI due to urethral hypermobility permits descent and may cause gaping of the UVJ, often referred to as 'funneling'. Urethroscopic findings typical of patient with ISD include poor coaptation (Plate 10) (Cundiff and Bent, 1999).
Plate 10 Poor coaptation
2- Detrusor instability (DI): Detrusor instability is suspected if there is uncontrolled urethral opening during filling. Trabeculations are also a common finding in women with detrusor instability, although they are not diagnostic of this condition (Cundiff and Bent, 1999).
3-Other causes of incontinence: Urinary incontinence that is not associated with urgency or stress may be due to urethral diverticula, vesicovaginal fistula or urethrovaginal fistula. Intravesical foreign bodies may present with hematuria or as urge incontinence, as the mucosal irritation can cause DI (Cundiff and Bent, 1999).
4- Pelvic changes
A subjective prediction of the architectural support of the bladder base can made from the cystoscopic view of the base and the position of bladder base structures. The bladder rests on trapezoid- shaped pubocervical fascia which is stretched between the arcus tendineus fasciae pelvis on either side. The arcus tendineus fasciae pelvis is the condensation of the pubocervical as it intercepts the fascia of the obturator internus muscle. They run from the posterior aspect of the symphysis pubis to the ischial spine. Superiorly, pubocervical fascia is contiguous with the cervix, which often protrudes into the bladder base creating recesses or vestibules laterally (Cundiff, 1999).
In patients with paravaginal defects, there is an exaggeration of these recesses as the lateral support of the bladder is compromised (Plate 11). This loss of lateral support also changes the position of ureteral orifices, which sag medially and may be seen in near apposition (kissing ureters), in women with bilateral vaginal defects (Plate 12). Midline defect in the pubocervical fascia is visualized as a drop off of the trigone and bladder base which may require a vaginal finger to visualize fully the mucosa of the base (Plate 13). A superior defect in the pubocervical fascia is seen as a sagging of the bladder dome with support of the trigone. Lateral position of the ureteral orifices tends to be preserved in this support defect. Combinations of paravaginal and midline defects can also be deduced from combinations of these findings (Plate 14) (Cundiff, 1999).
Plate 11 Right paravaginal defect
Plate 12 Bilateral paravaginal defects
Plate 13 Midline cystocele
Plate 14 Right and midline defect