What are the guidelines for preparing a patient for a cystoscopy procedure?

Cystoscopy Patient Preparation Guidelines

For simple diagnostic outpatient cystoscopy in healthy adults with sterile urine, antibiotic prophylaxis is not recommended, and the procedure can be performed under local anesthesia using a flexible cystoscope. 1

Pre-Procedure Assessment

Patient Risk Stratification

Determine infection risk before deciding on prophylaxis:

• Low-risk patients (healthy adults with sterile urine undergoing simple diagnostic cystoscopy): No antibiotic prophylaxis needed 1
• High-risk patients requiring prophylaxis include:
  • Patients with positive urine culture 2
  • Immunosuppressed individuals 1
  • Patients with neurogenic bladder dysfunction 1
  • Those with recent genitourinary instrumentation 1
  • Patients who have received recent antimicrobials 1

Urine Testing Requirements

Pre-procedure urinalysis should be obtained, but a positive dipstick alone in asymptomatic patients is not a contraindication to proceeding: 3

• Urine culture is only necessary if the patient has symptoms of UTI or falls into high-risk categories 2
• Do not routinely cancel cystoscopy based solely on positive urinalysis (leucocyte esterase/nitrites) if the patient is asymptomatic - this causes unnecessary delays without improving safety 3
• The risk of post-procedure UTI remains low (6.8%) even with positive pre-procedure urinalysis, with no cases of sepsis reported 3

Antibiotic Prophylaxis Decision Algorithm

For patients requiring prophylaxis, administer a single dose within one hour before the procedure: 1

• First-line options: First- or second-generation cephalosporins, trimethoprim-sulfamethoxazole 1
• Alternatives: Amoxicillin/clavulanate or aminoglycoside-ampicillin combination 1
• Route: Single oral dose is sufficient for most cases 1

Important caveat: Recent high-quality evidence shows that in patients with sterile urine undergoing diagnostic cystoscopy, antibiotic prophylaxis does not significantly reduce UTI rates (risk difference -0.009,95% CI -0.03 to 0.011) 4. However, prophylaxis remains indicated for the high-risk groups listed above 1.

Equipment and Anesthesia Selection

Flexible cystoscopy under local anesthesia is preferred over rigid cystoscopy for initial diagnostic procedures: 1

• Advantages of flexible cystoscopy:
  • Less pain and fewer post-procedure symptoms 1, 5
  • Simplified patient positioning 1
  • Reduced procedure time 1
  • At least equivalent diagnostic accuracy to rigid cystoscopy 1, 5
  • Superior visualization of anterior bladder neck lesions 1, 5

Required equipment: Flexible cystoscope, irrigant, lubricating gel, sterile gloves, and towels/drapes 6

Patient Positioning

• Male patients: Supine position 6
• Female patients: Frog-leg supine position 6

Special Populations Requiring Additional Monitoring

Neurogenic Bladder Patients at Risk for Autonomic Dysreflexia

Patients with spinal cord injury at T6 or above require continuous hemodynamic monitoring during cystoscopy: 1

• Have pharmacotherapy for autonomic dysreflexia readily available before starting 1
• If autonomic dysreflexia develops: Immediately terminate the procedure, drain the bladder, and continue monitoring 1
• If symptoms persist after bladder drainage (systolic BP >150 mmHg or >20 mmHg above baseline with symptoms): Initiate pharmacologic management and escalate care 1

High-Risk Patients for Bladder Cancer

Cystoscopy timing based on cancer risk stratification (post-TURBT surveillance): 1

• Low-risk tumors: First cystoscopy at 3 months, then at 12 months, then annually for years 2-5 1
• Intermediate-risk tumors: Cystoscopy with urine cytology at 3,6,9,12,18, and 24 months, then annually for years 3-5 1
• High-risk tumors: Cystoscopy with urine cytology every 3 months for 2 years, then every 6 months for years 3-5, then annually after year 6 1

Technical Considerations

For surveillance cystoscopy in bladder cancer patients, integrated dual-channel bladder catheters are recommended to prevent infection and reduce cystoscope damage (though this is a weak recommendation based on moderate evidence). 1

Common Pitfalls to Avoid

• Do not delay or cancel procedures solely based on asymptomatic positive urinalysis 3
• Do not routinely give antibiotics to low-risk patients with sterile urine - this contributes to antibiotic resistance without proven benefit 1, 4
• Do not perform cystoscopy during spinal shock following acute neurological events - wait until the condition stabilizes (typically 3-6 months, but can be up to 1-2 years) 1
• Do not skip hemodynamic monitoring in high-risk neurogenic bladder patients - autonomic dysreflexia can be life-threatening 1

Patient Subgroups at Higher Post-Procedure Infection Risk

Even without prophylaxis, certain groups have elevated UTI risk and warrant closer post-procedure monitoring: 3, 7

• Female patients (significantly higher risk on multivariate analysis) 7
• Diabetic patients (significantly higher risk on multivariate analysis) 7
• Patients with history of recurrent UTIs (OR 1.72) 3
• Patients found to have bladder tumors on cystoscopy (OR 2.22) 3

Note: Even in these higher-risk groups, prophylactic antibiotics have not been shown to significantly reduce infection rates 7.