Master Class

A Gynecologist's Procedure


Urology has long claimed the procedure as one that belongs within its realm of care, but for hundreds of years, gynecologic surgeons have used the cystoscope to examine the bladder. In doing so, they have not only evaluated fistulas and other occurrences, but have also authored many of the medical literature's notable papers on cystoscopy.

Gynecologists have also used the instrumentation to examine the urethra as well as the bladder. Dr. J.R. Robertson, an ob.gyn., is in fact the father of the urethroscope, which consists of an external sheath and a 0-degree lens.

In recent years, gynecologists have become more involved in evaluating problems such as bladder and pelvic pain, including interstitial cystitis, as well as recurrent urinary tract infection and overactive bladder symptoms.

Moreover, they have been performing increasing numbers of pelvic reconstruction procedures—and they have increasingly turned to cystoscopy, both to aid them in office diagnosis and to ensure surgical safety.

The evaluation of hematuria is still mainly within the realm of urologists.

Gynecologists' use of cystoscopy has become less controversial over the past decade as the lines between urology and gynecology have blurred, with gynecologists addressing more traditionally urologic issues and performing more procedures that were previously considered urologic, and vice versa.

Many gynecologists are using hysteroscopy to evaluate fibroids, abnormal uterine bleeding, and other symptoms, and for them, learning cystoscopy is an especially natural fit.

Even without the hysteroscopy backdrop, embracing cystoscopy with proper training is a natural and logical evolution for the specialty. In fact, an American College of Obstetricians and Gynecologists' Committee Opinion, issued in July, stated that cystoscopy is an important diagnostic and therapeutic tool, and that practicing gynecologists, especially gynecologic surgeons, should become comfortable with the routine performance of the procedure.

Office Cystoscopy

Cystoscopy is but one of several diagnostic tools and methods available for evaluating a number of indications, but it is proving to be a useful one. It can readily be performed in the office without the need for sedation.

The equipment needed to perform office cystoscopy includes a good light source; an endoscopic video system; a suitable hookup for a sterile water bag and related tubing; a cystoscope—preferably a narrow-angle scope (0–12.5 degrees)—to examine the urethra; and a wider-angle scope (70 degrees) to examine the bladder itself.

The urethra should be visualized first, with attention given to its anatomy, tone, and vasculature. It will look pink and spongy in a patient who is well estrogenized but pale and flat in someone who is atrophic. In a patient who has had a previous sling, the urethra should be evaluated for evidence of erosion.

Openings in the urethral wall that suggest diverticula, evidence of infection, and any other abnormalities can be identified. In women with stress incontinence, the severity of sphincteric deficiency can be evaluated by assessing urethral tone; someone with intrinsic sphincteric deficiency will have a patulous urethra and bladder neck.

We can also then evaluate mobility of the bladder neck—an area at which fronds, polyps, and cysts are normal variants—and the appearance of the trigone, or the posterior wall of the bladder right above the bladder neck.

Cystoscopy enables us to visualize various degrees of inflammation and to detect chronic trigonitis, an inflammatory condition that can present in women who have symptoms of recurrent urinary tract infection but negative urine cultures. Confirmation of the condition can usually be achieved with vaginal palpation of the trigone.

In visualizing the ureters, which is the next step in the office evaluation, our goal is to thoroughly evaluate the anatomy of the lower urinary tract. We can then examine the rest of the bladder, looking for evidence of obvious abnormalities like stones, tumors, diverticula, and inflammation. A 70-degree scope allows visualization of the entire bladder wall, including the lateral walls where a sling/suture erosion could occur.

We can also look for trabeculations, which are thick ridges observed in the middle of the bladder wall. Such patterns are sometimes a result of normal aging but they are also often found in patients with detrusor overactivity. Diverticula of the bladder can also be visualized; such abnormalities can be responsible for urinary retention.

Bladder tumors can take on various appearances, from flat white areas to cauliflowerlike papillary lesions. Although some cancers are obvious, other low-grade cancers can be extremely subtle in appearance. Persistent hematuria, especially in a smoker, should prompt us to perform a careful cystoscopy to look for tumors. If there is any question of malignancy, a biopsy can be performed in the office or upon referral to a urologist.

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