What is the recommended treatment for bladder spasms during a cystoscopy (CBI) procedure?

Treatment of Bladder Spasms During Continuous Bladder Irrigation (CBI)

Administer anticholinergic medications, specifically oxybutynin or tolterodine, as the primary pharmacologic treatment for bladder spasms occurring during continuous bladder irrigation. 1, 2

Pharmacologic Management

First-Line Anticholinergic Therapy

• Oxybutynin is the most commonly used agent, with immediate-release formulations typically started at 2.5 mg three times daily to minimize side effects while maintaining efficacy 2

  • This low-dose regimen achieves a 95% positive response rate with only 30% of patients reporting side effects, compared to higher rates with standard dosing 2
  • The dose can be escalated to 5 mg three times daily if initial response is inadequate and no side effects occur 2

• Extended-release tolterodine 4 mg once daily is an alternative with superior tolerability profile 3

  • Results in 70% of patients perceiving improved bladder condition with lower severity of dry mouth compared to extended-release oxybutynin 10 mg 3
  • Fewer patients withdraw due to poor tolerability (6% vs 13% with oxybutynin) 3

Alternative Anticholinergic Options

• Belladonna and opium (B&O) suppositories, while historically used for prophylaxis, show no significant reduction in bladder spasm rates (OR 0.91, p=0.318) 1
  • Despite widespread use in 1,158 patients undergoing urologic procedures, 33.2% still developed spasms 1
  • This evidence suggests B&O suppositories should not be relied upon as primary prophylaxis 1

Understanding Risk Factors and Incidence

High-Risk Scenarios for Bladder Spasms

• Bladder spasms occur in 34.3% of patients following cystoscopic urologic procedures, with an incidence of 343 per 1,000 procedures 1

• Transurethral resection procedures carry the highest risk 1:

  • TURBT increases risk 4.35-fold compared to simple cystoscopy 1
  • TURP increases risk 3.25-fold compared to simple cystoscopy 1

• Younger patients (<60 years) and longer procedures (>45 minutes) are associated with increased spasm risk 1

Practical Management Algorithm

During Active CBI

1. Initiate oxybutynin 2.5 mg three times daily as first-line therapy when spasms develop 2

2. Assess response after 2 weeks 2:

   • If inadequate relief and no side effects: escalate to 5 mg three times daily 2
   • If intolerable side effects: switch to extended-release tolterodine 4 mg daily 3

3. Monitor for anticholinergic side effects including dry mouth, constipation, and urinary retention 2, 3

Special Considerations for Intravesical Administration

• Intravesical oxybutynin 5 mg/30 mL three times daily can be considered in refractory cases 4
  • Achieves therapeutic serum concentrations with a more favorable parent drug/metabolite ratio compared to oral administration 4
  • Significantly reduces daily toilet visits from 6.9 to 5.7 (p=0.022) 4
  • However, this route requires catheter access and is more complex to administer 4

Critical Pitfalls to Avoid

• Do not rely on B&O suppositories as primary prophylaxis or treatment, as evidence shows no significant benefit 1

• Avoid starting with high-dose anticholinergics, as low-dose oxybutynin (2.5 mg TID) achieves 95% response rates with significantly fewer side effects than standard dosing 2

• Do not discontinue CBI prematurely due to spasms, as postoperative outcomes do not differ between patients who develop spasms versus those who do not 1

• Recognize that bladder spasms during procedures requiring carboprost instillation are expected and develop in nearly all patients, but are typically not severe enough to discontinue therapy 5