Office based cystoscopy is one of the most common procedures in daily urology practice, as it allows adequate and feasible visualization of the bladder and urogenital system. It is used in the diagnosis and follow-up of urogenital malignancies, as well as for noncancer related diagnoses. In men flexible cystoscopy is the first choice procedure in the outpatient clinic, since this method is less painful compared to rigid cystoscopy [1]. However, in women rigid and flexible cystoscopy are both still routinely used in an office based setting. The underlying theory is that both rigid and flexible instruments can easily pass the short female urethra without much discomfort. Cystoscopy, however, is an invasive procedure which can be associated with pain and discomfort [2]. Literature is conflicting whether type of cystoscopy is associated with pain in women. A number of studies have investigated pain perception and degree of discomfort in women undergoing an office based cystoscopy [234567891011]. Only in 2 of these studies, female patients were randomized for rigid and flexible cystoscopy to compare pain perception in both groups [810]. These 2 relatively small studies did not find any difference in discomfort and pain perception between rigid and flexible cystoscopy procedures. Another study demonstrated that both rigid and flexible cystoscopies were well tolerated, but the use of flexible cystoscopy was preferred by the majority of patients [9]. One large analysis of 1,320 patients showed that cystoscopy procedures were not associated with distressing levels of pain [11]. In addition, this study found that using flexible cystoscopy was associated with a lower pain level in both men and women.

The question arises whether the conflicting data in literature may be explained by the fact that all aforementioned studies varied in methodology and data collection. In addition, in both randomized controlled trials, some patients have already undergone previous cystoscopy procedures, which may influence patient's pain perception. Therefore, we investigated in a large case control study of female patients, who underwent first time cystoscopy, whether using flexible cystoscopy leads to less discomfort and pain compared to rigid cystoscopy.

Patient characteristics are presented in Table 1. A total of 189 patients were included, of which 97 underwent flexible cystoscopy and 92 rigid cystoscopy. Overall, female patients were 58±17 years old and the most common indications, for which a cystoscopy was performed, were hematuria (29.1%), LUTS (27.5%) and recurrent urinary tract infections (26.5%). Cystoscopy had in 76 patients no effect on their pain experience and the overall median VAS score was 9 (0–25) mm. None of all patients had any pain feelings 30 minutes after procedure. Table 1 also shows the patient characteristics stratified for treatment group. Patients who underwent rigid cystoscopy, reported significantly more frequent pain compared to the flexible cystoscopy group (71.7% vs. 48.5%, p=0.001). Their pain experience, expressed as VAS score, was also significantly higher in the rigid cystoscopy group compared to the flexible cystoscopy group (15 [0–38] vs. 0 [0–20], p<0.001) (Table 1).

In addition, we investigated whether other patient characteristics were associated with their pain experience. Overall, age was inversely associated with VAS score (overall R=−0.30, p=0.001) (Fig. 1). This association was also seen in patients who underwent rigid cystoscopy (R=−0.35, p=0.004), whereas a trend was found in the flexible cystoscopy group (R=−0.23, p=0.075), likely due to the relatively small number of patients per treatment group. Indication for cystoscopy, performing urologist and sex of urologist were all not associated with pain experience (p=0.253, p=0.136, and p=0.474 respectively).

Lastly, we performed univariate and multivariable linear regression to investigate whether type of cystoscopy was associated with pain experience in female patients (Table 2). As expected, flexible cystoscopy was univariately associated with a decrease in VAS score (standardized β=−0.22, p=0.002) and remained significant after adjusted for age (standardized β=−0.23, p<0.001) (Table 2, model 2). In the final model, flexible cystoscopy was still associated with a decrease in VAS score after adjustment for age, performing urologist, sex of urologist and indication (standardized β=−0.17, p=0.048) (model 3). Moreover, age remained inversely associated with VAS score (standardized β=−0.30, p<0.001).

This study showed that in female patients, who underwent first-time cystoscopy, pain experience was significantly lower in the flexible cystoscopy group compared to the rigid cystoscopy group. We found that age was inversely associated with pain experience during cystoscopy. The association between flexible cystoscopy and pain experience remained significant after adjustment for age, cystoscopy performing urologist, sex of the urologist and cystoscopy indication.

Literature is conflicting whether type of cystoscopy is associated with pain experience. Only 2 randomized controlled trials were performed that compare flexible and rigid cystoscopy on pain experience [810]. These studies found that flexible as well as rigid cystoscopy were well tolerated in women and discomfort and pain were minimal during procedure. Clinicians should therefore perform cystoscopy in women based on their preference and skill level. In contrast to their results, we found that female patients experienced less pain using flexible cystoscope compared to rigid cystoscope.

Four reasons came to mind which may possibly explain this contrast. In both studies, some patients have already undergone previous cystoscopy procedures, which may influence patient's pain perception. Indeed, studies found that pain levels during first cystoscopy procedures were higher than those for repeated ones [1113]. Our results were based on patients with no history of previous cystoscopy treatments, to avoid a source of bias based on preconceived notions. Secondly, in our study all procedures were performed by urologists with great experience in performing cystoscopies. In the study of Gee et al. [10], a large part of the procedures was performed in a teaching setting. Despite flexible and rigid cystoscopy could be performed adequately by resident urologists, such a result is presumably dependent on good instruction and supervision [14]. Thirdly, an urethral local anesthetic (lidocaine gel or Xylocaine 2% respectively) was used in both studies, whereas this was not the case in our study. Lastly, the lack of significant differences and associations may be due to the small sample size. Gee et al. [10] performed a prospective randomized single blind 2 arm study with only 31 out of 36 participating women, to determine whether office based flexible cystoscopy was better tolerated than rigid cystoscopy in women. Although one hundred women were enrolled primarily in the study of Quiroz et al. [8], a drop out of 15% occurred.

Our study indicates that also age plays a role on pain experience. This is in accordance with an earlier study. They found a trend that age was associated with pain during cystoscopy in a large population of men and women [11]. The reason why age seems to play an important role in causing pain symptoms cannot be concluded from the present data. However, we hypothesize that indication for cystoscopy might be important. In young women, cystoscopy is performed in many cases to evaluate recurrent urinary tract infections, whereas in older women the indication for cystoscopy is more frequently to evaluate incontinence or hematuria.

In our study, per protocol, no lubricant, including anesthetic or antiseptic gels, was utilized [12]. Both the flexible and rigid cystoscopes were introduced with running NaCl 0.9% solution, used as a natural lubricant. We decided not to use any lubricant gel, because it has been suggested that lubricant gel itself could induce pain due to distension of the urethra and the sphincter [1516]. It is intriguing that 51% of our flexible cystoscopy treatment group had a VAS score of 0 mm. These results suggest that performing a flexible cystoscopy in women, except for young women, lubricant with or without anesthesiological component is not really necessary. Excluding lidocaine jelly or plain lubricant may lead to significant cost savings.

This study has strengths and limitations. A limitation of our study is that it was not performed blinded to the cystoscopical procedure. However, since all patients had no experience with the procedure, we think this might not bias our results. Another limitation is that significant more male urologists performed rigid cystoscopy procedures. Although, after adjustment for sex of performing urologist, flexible cystoscopy was still associated with a decrease in VAS score. In addition, no interaction was found between VAS score and sex of performing urologist. So, a possible (sub) conscious bias in favor of female doctors being more gentle seems to be excluded. The main strength of our study is the systematic and prospective nature of data collection that resulted in a well-phenotyped population.

We found that female patients who underwent flexible cystoscopy for the first time had a significantly lower VAS score compared to rigid cystoscopy. This association remained significant after adjustment for age, performing urologist, sex of urologist and indication for cystoscopy. Based on patient's pain experience, our study implicates that physicians may use flexible cystoscopy as first choice procedure in female patients who undergo first time cystoscopy.