For a patient scheduled for cystoscopy who is taking Norco (hydrocodone/acetaminophen), how should the preparation be managed regarding bladder fullness, continuation of the medication, pre‑procedure fasting, and sedation considerations?

Cystoscopy Preparation for Patients Taking Norco

Continue Norco (hydrocodone/acetaminophen) on the morning of cystoscopy, ensure the patient arrives with a comfortably full bladder (not empty, not overly distended), and no formal fasting is required for diagnostic cystoscopy under local anesthesia or minimal sedation. 1

Medication Management

Continue Norco Through the Procedure

• Patients on chronic opioid therapy should continue their baseline opioid regimen on the morning of the procedure. 1 This maintains baseline pain control and prevents withdrawal symptoms.
• Hydrocodone/acetaminophen (Norco) should be taken as scheduled, as abrupt discontinuation provides no benefit and may worsen perioperative pain management. 1
• Patients on chronic opioids will likely require higher-than-usual doses or adjunctive nonopioid analgesia for adequate procedural pain control. 1

Sedation Considerations

• Diagnostic cystoscopy does not require antibiotic prophylaxis. 1 This is a key distinction from therapeutic procedures like ureteroscopy or transurethral resection.
• If intravenous sedation is planned (typically midazolam with or without an opioid), the doses must be carefully titrated in patients already taking Norco. 1
• When combining benzodiazepines with opioids, reduce both drug doses by up to fourfold due to synergistic (not additive) respiratory depression risk. 1 Administer the opioid first, then titrate the benzodiazepine carefully.
• Midazolam is superior to diazepam for cystoscopy sedation, providing better sedation, decreased pain, and reduced procedure recall. 2

Bladder Preparation

Optimal Bladder Fullness

• The patient should arrive with a comfortably full bladder—not empty, but not painfully distended. 1 This facilitates initial visualization and reduces the need for aggressive bladder filling during the procedure.
• Instruct the patient to drink 16-24 ounces of clear fluid 1-2 hours before the scheduled procedure time.
• A completely empty bladder makes initial cystoscope insertion and orientation more difficult, while an overly distended bladder increases patient discomfort and anxiety. 3

Hydration Strategy

• Encourage oral hydration with clear fluids up to 2 hours before the procedure. 1 Plain water is preferred.
• Avoid requiring the patient to void immediately before cystoscopy unless bladder distension is causing significant discomfort.

Fasting Requirements

Minimal Fasting for Diagnostic Cystoscopy

• For diagnostic cystoscopy under local anesthesia or minimal sedation, no formal fasting is required. 1 Clear liquids are permitted up to 2 hours before the procedure.
• Light meals may be permitted up to 6 hours before if only local anesthesia is planned. 4
• If moderate sedation (propofol or deeper sedation) is planned, follow standard NPO guidelines: clear liquids until 2 hours before, light meals until 6 hours before. 4

Pain Management Strategy

Multimodal Analgesia

• Maximize nonopioid agents for baseline pain control unless contraindicated. 1 This includes acetaminophen and NSAIDs.
• Oral acetaminophen (1000 mg) given 1-2 hours before the procedure is as effective as intravenous formulation and is associated with fewer side effects for cystoscopy. 5
• Consider scheduled acetaminophen 1000 mg every 6 hours combined with ibuprofen 800 mg every 8 hours in staggered fashion for patients without contraindications. 1

Expected Opioid Needs

• For diagnostic cystoscopy, the recommended opioid prescription is 0 tablets postoperatively. 1 Most patients do not require opioids after diagnostic cystoscopy.
• Patients already taking Norco should continue their baseline regimen but should not routinely receive additional opioids for diagnostic cystoscopy. 1
• Bladder spasms are the major contributor to severe postoperative pain (occurring in approximately 29% of cases) and may require anticholinergic medications rather than additional opioids. 5

Monitoring and Safety

Cardiorespiratory Monitoring

• For patients receiving any sedation, pulse oximetry is mandatory, particularly in elderly patients, those with chronic lung disease, or those receiving combined opioid-benzodiazepine sedation. 1
• Supplemental oxygen should be available and administered if oxygen saturation falls below 90%. 1
• A qualified nurse trained in endoscopic techniques must be present throughout the procedure, dedicated solely to patient monitoring. 1

High-Risk Patient Identification

• Patients taking chronic opioids like Norco are at increased risk for respiratory depression when additional sedation is administered. 1
• Elderly patients, those with cardiac or pulmonary disease, and those with hepatic or renal impairment require dose adjustments and closer monitoring. 1

Common Pitfalls to Avoid

• Do not abruptly discontinue Norco before the procedure. 1 This provides no benefit and may worsen pain control and precipitate withdrawal.
• Do not require complete bladder emptying immediately before cystoscopy. 1 A comfortably full bladder facilitates the procedure.
• Do not use full doses of both benzodiazepines and opioids together. 1 The synergistic effect dramatically increases respiratory depression risk.
• Do not routinely prescribe additional opioids after diagnostic cystoscopy. 1 Most patients manage well with nonopioid analgesia alone.
• Do not administer antibiotic prophylaxis for diagnostic cystoscopy. 1 It is not indicated and contributes to antimicrobial resistance.
• Avoid meperidine (Demerol) in patients with renal insufficiency or in combination with other serotonergic medications. 1 Norco (hydrocodone) is a safer alternative.

Scheduling Considerations

• Scheduling cystoscopy in advance (rather than performing it immediately on the day of consultation) significantly reduces patient anxiety and pain scores. 3 This allows time for proper patient education and mental preparation.
• Provide both verbal and written instructions about medication continuation, hydration, and what to expect during the procedure. 3